Inspection on 28/08/06 for Croftlands

This inspection was carried out on 28th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croftlands 12/09/07

Croftlands 10/02/06

Croftlands 22/07/05

Croftlands 10/03/05

Croftlands 15/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Croftlands 41 Durranhill Road Carlisle Cumbria CA1 2SW Lead Inspector Liz Kelley Unannounced Inspection 28th August 2006 09:30 Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croftlands Address 41 Durranhill Road Carlisle Cumbria CA1 2SW 01228 524296 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Croftlands Trust Ms Penny Poxon Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. To accommodate nine people in the category of Mental Disorder (1MD). To accommodate one named person in the category MD(E) (1 MD(E) Date of last inspection 10th February 2006 Brief Description of the Service: Croftlands accommodates up to 10 people who have difficulties in maintaining aspects of their mental health. The intention of the service is that people can live in the home for up to three years. The goal is to help service users move onto other accommodation where they can live as independently as possible. The premises are a large detached three-storey Victorian style property, which has been modernised and converted for its current usage. The house is situated in a suburb of Carlisle and stands in its own walled gardens with a driveway leading up to the entrance. Each service user has an individual bedroom with wash hand basin, and each floor has a bathroom or shower room. There are two lounges and two kitchens on the ground floor; one of the lounges is designated as a no-smoking area. The home has a zero tolerance on illegal drugs. An office, staff room and staff sleeping in room is also provided. Croftlands is run by The Croftlands Trust; this is a non-profit making organisation, which runs a number of residential and community based services in the County for people with mental heath problems. Locally the home is also known as Durranhill. A Service Users Guide is available for prospective residents, with details of how to get the latest Inspection report. Placements and referrals are funded and managed via Mental Health NHS Trust. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key standards were examined and included two visits to the home. On the first visit, 21/07/06, time was spent with service users to seek their experiences of using the service. On the second visit 28/07/06 the deputy was available to assist in the inspection; and staff, resident’s records and administration files were examined. Feedback cards had been received from residents, relatives and professionals. A tour of the building was carried out, and the home returned a questionnaire which included the latest details of the service. What the service does well: What has improved since the last inspection? What they could do better: The home lacks clarity on its current purpose and direction. The amount of work in meeting the needs of service users, many of whom have far more Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 6 complex and challenging needs than before, and keeping up with administration of the home, has become more than this management structure can cope with. Service users needs are not always thoroughly assessed prior to admission and this can have a detrimental effect on developing care plans, and consequently the care that is given does not always meet the needs of service users. Overall care planning is inconsistent and many plans lack any form of progress or meaningful goals for the individual. Identification of mental health need is particularly poor, with plans being developed along basic maintaince programmes. The use of these daily reports, monthly reports and care planning should be reviewed with a view to making them relevant to meeting mental health needs and proactive and engaging of service users. The organisation has already identified a need to find different ways of engaging with service users with a preferred model of working with people with mental health problems. This needs to be perused with some urgency and in the meantime assessments and the care planning system should be improved for those currently using the service. Staff would benefit from up-to-date training on Adult Protection and the procedures for referring incidents to social services. The home could improve its recruitment procedure by including residents as part of the selection procedure for new staff. A Training matrix is recommended for the home which would help in identifying shortfalls, along with individual training files with copies of certificates would also be good practice. This would help to develop staff training in a way that meets the needs of the individual and provides service users with a balanced and well-qualified staff team. The homes systems of recording and dispensing medication should be reviewed to reduce recurring errors. In particular medication must be recorded accurately, and any errors must be reported to Commission for Social Care Inspection. Please contact the provider for advice of actions taken in response to this inspection. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home lacks clarity on its current purpose and direction. Service users needs are not always thoroughly assessed prior to admission and this can have a detrimental effect on developing care plans, and delivering care. EVIDENCE: At the last inspection the organisation was recommended to review the homes aims and Statement Of Purpose document in light of changing referrals and changes in mental health provision in the area. The home is currently divided between those who consider Croftlands their home and have lived there several years and those who are only likely to stay for several months. This can cause frictions between service users and a conflict in approach for staff between crisis intervention and those who are long-term residents. Staff in the home were not clear on future directions and plans for the home. Clarity of purpose is needed to give a consistent approach to service users and to be responsive to the changing provision in this field. Although future planning for individual service users is improving, the home still lacks clarity of direction in the service it aims to provide. While the majority of service users had assessments prior to entering the home this was not always the case, especially in emergency placements. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Overall care planning is inconsistent and many plans lack any form of progress or meaningful goals for the individual. Identification of mental health need is particualrly poor, with plans being developed along baisc maintaince programmes. EVIDENCE: Care planning and care plans are inconsistent and do not always identify the need and steps that staff need to take to meet required outcomes. While some have very detailed contingency plans for crisis intervention, other care plans are not up to date and not consistent with other records; some contain very little information on meeting mental health needs. From information in certain care plans it was unclear why some people required residential care. The report system that staff use is time consuming and difficult to follow. Staff are recording the same statements over and over, and the use of these reports seems limited in meeting residents needs. This makes it difficult to find important information. Instructions to staff on the care and support to give is passed on in an adhoc manner. For example verbally at staff hand over and much of this was about day-to-day issues. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 11 These plans are presently being reviewed by night staff to help these staff feel more involved. This was discussed with the deputy who agreed that this was not an effective way of doing this, as these staff have less knowledge of residents and the involvement in residents was also limited. These factors result in care plans that are not always relevant or meeting the assessed needs of service users. The use of these daily reports, monthly reports and care planning should be reviewed with a view to making them relevant to meeting mental health needs and proactive and engaging of service users. The organisation has already identified a need to be more proactive with service users and has identified a preferred model of working with people with mental health problems. This needs to be perused with some urgency and in the meantime assessments and the care planning system should be improved for those currently using the service. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All the above Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are committed to helping service users to maintain positive relationships with family and friends; and in promoting appropriate links with the local community. EVIDENCE: The staff group is stable and skilled at assisting people with mental health needs. Service users valued the support and understanding of the staff team. Decision-making has a high profile in the home and the staff team are skilled at enabling service users to make choices. Emphasis is on what service users can do rather than cannot. There is evidence of staff engagement with service users in the home, by discussions with resdeints and staff. As mentioned in the previous section the homes recording and planning of this work is patchy and needs to improve. Lately the staff team have supported service users to have outside interests and attend college courses to help them with moving on from the home. This has been a good postive feature of the home recently which needs to be developed further, and reflected in careful care planning and recording. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 13 Staff are also supportive of the family and relationship dynamics for each person. Example were staff going with service users all over the country to attend weddings, funerals and family get-togethers. Where, appropriate family were encouraged to visit and arrangements are made to allow privacy on these visits. The home has a well-balanced staff team, with a good age range and gender mix. Individual talents and interests of staff are put to good use to support the equality and diversity needs individuals’ cultural and spiritual interests. Mealtimes and menus are flexible around resident’s choice and dietary needs. Although there is a weekly shop for the house where service users choose to take part, individual shopping is also encouraged to develop independence and daily living skills. There was evidence of recent consultation on meals, for example for Sunday dinners, less joints and more chops and turkey were requested. Service users can make their own meals and buy their own food, with or without staff support. Service users are given a high degree of choice about their diets, and a number of relative comment cards expressed that there was too much junk food. However, staff are given training on the importance of healthy diets and the role in promoting good mental health for service users. Some service users recently commented on their being no communal dining room. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for recording administration of medicines were generally satisfactorily managed and service users were encouraged to self medicate, and make positive choices on their health and well-being. EVIDENCE: Records confirmed that service users had access to a full range of general health care services and more specialised services, such as psychiatrists, community psychiatric nurses and behaviour specialist. On the day of inspection one service user was being supported to attend an appointment with psychiatrist. Croftlands medicines handling policies and procedures were in place. Receipt of medicines was recorded. The medicines that were stored were audited regularly and a running total was kept. A new system was in place for ordering medicines. This meant that there were no medicines out-of-stock and residents had access to the medicines they required. Protocols for the administration of “when required” paracetamol were in place. Residents’ doctors provided written authorisations for the administration of Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 15 homely remedies and this was an example of good practice. This means that residents have fast access to treatment for self-limiting minor ailments. Residents were able to self-medicate if they wished and were assessed as safe to do so. Risk assessments were in place and recent medication care plans contained good instructions for moiniting compliance and safety. However, staff on occasions are not accurate when recording medications. There were missed signatures for administration. This puts residents at risk from duplicate administration if staff administer a medicine that has already been given but not signed for. The home received printed MAR sheets from Boots which are designed to tally with printed labels on medicines but were chosing not to use these, instead making up Croftlands own sheets. On checking names and doseage on these sheets they were different – one used a trade name the other the medical name. The member of staff on duty knew these were the same, but this could potentially cause confusion. Another example was the measured dosage amounts which again has potential confusion. If the home wishes to continue using their own sheets a more robust system is needed, and as errors are occuring frequently a system of double checking is advised to reduce errors. These errors have been noted for at least last four inspections, and are frequently commented upon on the visited by the line manager carrying out regualtion 26 monitoring visits which are sent into CSCI. The manager had introduced measures to attempt to reduce errors, staff have to check the MAR sheets at shift change, when staff make mistakes they receive a letter explaining the seriousness and need for care and attention. The home is not sending in regualtion 37s re missed meds or errors, and this should commence. A Boots pharmacy visit was carried out 26.6.06 by and no issues were identified. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has improved its systems to protect service users from abuse and to protect their rights. The home has a satisfactory complaints system with residents being able to express their views on the home, and these are acted upon. EVIDENCE: The Home has a complaints procedure, with a response time of 28 days. A system was in place to record all complaints. All service users have a copy of the complaints procedure, and details of how to complain were posted in the home. Up-to-date information about the Commission for Social Care Inspection was included. Most residents and others associated with the provision understand how to make a complaint. Service users were observed freely expressing opinions to staff, and other ways of expressing views more formally via the complainants procedure were seen. The open atmosphere created within the home ensures that service users feel free to express their opinions and are confident that they will be listened to and concerns acted upon A recent survey carried out by the home received positive feedback from relatives with all stating that they felt “confident that complaints will be listened to, taken seriously and acted upon”. However the majority answered “Don’t know” to the question “ There is a simple, clear and accessible complaints procedure”. The deputy described and demonstrated a revision of financial procedures to further strengthen them and protect service users from financial abuse. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 17 The policies and procedures regarding protection of people who use the service are satisfactory but need to be reviewed and updated in line with regulations and other external guidance. The Home has induction training that covers basic adult protection issues and the various forms of adult abuse. However, senior staff within the home have not received up-to-date training on local adult protection guidance, and the booklet on this guidance could not be found on the inspection visit. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that generally meets the needs of the residents who live there. The home is not being kept clean and hygenine levels are unacceptable. EVIDENCE: The home is comfortable, and has a rolling programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and improvements tend to be reactive rather than proactive. The furniture and inside of the building show evidence of heavy wear and tear. Service users recently made a group decision to limit smoking to the front vestibule to try to limit the damage caused to carpets and furniture in the lounges. A new lounge suite is to be purchased shortly, and a very large flat screen TV has been purchased for the lounge. These were all done with consultation with service users. A new kitchen was being fitted during the inspection visit. Some service users recently commented on their being no communal dining room. The home is not always clean and tidy, domestic cleaning arrangements are not adequate and cleaning is carried out by care staff. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 19 At the last inspection this area was highlighted with the manager and discussed with the Director of Croftlands Trust, and it was agreed that a commercial cleaning company gave the home a spring clean. This has been carried out, and carpets had also been steam cleaned. The home still remains unclean and a cleaner is needed to do basic cleaning on a regular basis. If service users do cleaning and domestic chores this needs to be identified in each persons care plan and be an integral part of a treatment plan, and not an alternative to employing a cleaner. Due to the complexity of the needs of service users currently being referred to the home it has been difficult for staff to spend valuable time away from service users in cleaning the home. Staff have become demoralised by these tasks and their skills and training need to be put to better use. The home must employ a cleaner. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, and 36 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a recruitment procedure that is adequate and generally meets the regulations and the national minimum standards although at a basic level. Development and supervision of staff is inconsistent and the number of qualified staff is below the expected standards. EVIDENCE: Residents are generally satisfied that the care they receive meet their needs, but there are times when residents feel that staff don’t take time to ensure they understand them. All staff are clear regarding their role and what is expected of them. The majority of residents report that staff working with them know what they are meant to do, and that they are able to meet their needs. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. While the majority of recruitment practices were satisfactory the manager needs to ensure that the home has up-to-date duplicate copies from HR department and that copies are held of a persons training record and their ID information. The selection procedure includes obtaining two written references, and a formal interview. All staff have enhanced level CRB disclosure checks. Upon appointment staff are issued with a handbook, which includes job descriptions Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 21 and terms and conditions. Appointments are subject to a six-month probationary period. The Croftlands Trust has a code of conduct and all members of staff have a statement of terms and conditions. The home could further improve its recruitment procedure by including residents as part of the selection procedure for new staff. The home has a framework for supervisions and appraisals, and were these have been carried out they are done to good standards; especially to identify support needs of staff. Supervisions, however need to be on a more regular basis. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The organisation has a training team to deliver and organise training for its workers. The manager is aware that there are some gaps in the training programme and plans to deal with this. The service is also able to recognise when additional training is needed and uses its connections with the mental health team to access short courses. The Home has only one member of care staff qualified to a minimum of NVQ level 2 in Care. This was required to be a minimum of 50 by 2005. Three more have been identified as candidates for the next group to be enrolled. Care staff have completed other short training courses to help them in their role, for example all staff have completed Level 2 in medication handling, one staff Health and Safety at work, and a number of short courses on Management of violence and break way techniques. Both the manager and the deputy have completed training suitable to support their role ie Supervision courses recruitment and selection, Appraisal and Objective setting. A Training matrix is recommended for the home which would help in identifying shortfalls, along with individual training files with copies of certificates would also be good practice. This would help to develop staff training in a way that meets the needs of the individual and provides service users with a balanced and well qualified staff team. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39 and 42 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to monitor quality. However, the outcomes need to be better co-ordinated in a structured development plan to ensure that the organisation is offering a consistently good quality provision to all those using the service. EVIDENCE: The manager is qualified and has the necessary experience to run the Home; and is aware of and works to the basic processes set out in the NMS. The manager trains and develops staff that are generally competent and knowledgeable to care for younger adults with mental health problems. The service is planned to be user focused, and works in partnership with families of residents and professionals. The manager is improving and developing systems that monitor practice and compliance with the homes plans, policies and procedures. More work is needed in this area to ensure consistency of the systems already in place, for example frequency and up-dates of care plans, staff supervisions, and other Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 23 quality assurance indicators. Checks show that records are generally up to date although some gaps are found in recording and entries are not always clear. The provider, The Croftland Trust, appoints an operations manager to carry out Quality Assurance checks (regulation 26 visits). These are sent into the Commission for Social Care Inspection on a monthly basis. From these reports areas for improvement are highlighted and the actions were checked at inspection. The areas for improvement were in line with those also confirmed during this inspection. The most common recurring issues are errors in medication and a need to improve and up-date care plans. The home and the organisation need to ensure that these are taken forwarded and a development plan for the home is structured, to take into account the views from a recent service user satisfaction survey. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. A member of staff is designated to ensure health and safety issues are met in the home and another member of staff is a designated fire warden, both have received training for these roles. The current manager also manages other projects for Croftland Trust and this limits hours spent in the home to a few a week. The deputy therefore, effectively manages the home and has designated management hours 9 to 5 weekdays to do this. The amount of paperwork and work organising service users, many of whom have far more complex and challenging needs than before, has become more than this management structure can cope with. In effect the home does not have a deputy or senior to share these duties with, and consequently the management role and systems have been detrimentally effected. This is illustrated in other sections of the report, for example care planning needs an overhaul, staff development and supervision requires coordinating. These are all jobs that could not reasonably be expected from the present management structure. Staff and managers are working to capacity and although are hard working and dedicated this results in the home lacking effective co-ordination. Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 3 x x 3 x Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3 4 Standard YA20 YA30 YA2 YA6 Regulation 13 23 14 15 Requirement Medications must be recorded accurately (Previously set at 31/03/06) The home must be kept clean and hygienic (Previously set at 30.04.06) A copy of new service users assessments must be received prior to admission The registered manager must develop and agree with each service user an individual Plan, which includes treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs, aspirations and goals. Timescale for action 30/09/06 30/09/06 30/09/06 30/11/06 Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA1 Good Practice Recommendations The homes systems of recording and dispensing medication should be reviewed to reduce recurring errors The home should review its aims to reflect the needs of the service users group in the home and trends within the Mental Health field. This should include a review of the management structure to be more effective in meeting the needs of the home. A Training matrix is recommended for the home, to monitor how they are to meet the expected standards Residents should be actively encourage to take part in staff selection Supervision needs to be on a more frequently and consistent basis A Development plan should be developed for the home 3. 4 5 6 YA35 YA34 YA36 YA43 Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Croftlands DS0000022572.V291986.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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