Inspection on 20/04/06 for Croftside

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Croftside 31/07/07

Croftside 23/11/05

Croftside 29/06/05

Croftside 22/11/04

Croftside 06/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Croftside Beetham Road Milnthorpe Cumbria LA7 7QR Lead Inspector Mrs Margaret Drury Unannounced Inspection 20th April 2006 09:40 X10015.doc Version 1.40 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 Croftside DS0000036503.V289150.R01.S.doc Version 5.1 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 Older People. 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. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Croftside Address Beetham Road Milnthorpe Cumbria LA7 7QR 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) 015395 63325 www.cumbriacare.org.uk Cumbria Care Mr Terence Michael Pollard Care Home 34 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (34) of places Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The Service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of thirtyfour (34) older people (OP) may be accommodated, ten (10) of whom may have dementia (DE/E). The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults by 1st April 2004. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, and when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. 23rd November 2005 5. Date of last inspection Brief Description of the Service: Croftside is owned by Cumbria Care, an internal business unit of Cumbria County Council. The home is operated on a daily basis by Mr Terry Pollard and is registered to care for up to thirty-four older people, including ten with various forms of dementia. The home is situated in a residential area of Milnthorpe and is close to all local amenities, shops and bus routes. It is purpose built and situated over two floors, the upper floor being serviced by a passenger lift. All rooms are currently used for single occupation. The home provides lounge and dining facilities with a large lounge that can be used for group activities, visiting entertainers or parties. There is also a small smoking area. All have wash hand basins and there are three with en-suite toilet facilities. The toilets and bathrooms are equipped to assist people with a physical disability. There are well kept gardens around the building and car parking facilities are provided. The home provides a statement of purpose and terms and conditions that give any prospective resident and/or their families details of the facilities on offer. There is also a copy on display in the hall. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 5 The fees in this service range from £317.00 - £422.00 per week as at April 2006. There are extra charges for Chiropody, hairdressing, newspapers, toiletries and taxi fares. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that took place over one day on the 20th April. As the registered manager was still on long term sick leave the acting manager was available to assist with the inspection. During the inspection, time was spent talking with the acting manager, the supervisors and care staff on duty. The inspector also spent time looking at records to do with the day-to-day running of the home and the care of residents. The report refers to “case tracking”, a process by which the inspector is able to focus on a small number of residents and includes a review of their care documentation. It should be noted that this process is not detrimental to the other residents living in the home Time was spent with some of the residents individually and in groups, and some parts of the home were looked at. What the service does well: What has improved since the last inspection? There have been no changes within the home since the last inspection. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this area is good. This judgement has been made using the available evidence including a visit to the home. Residents benefit from a comprehensive admission process that includes a full assessment of needs and capabilities. Each resident is provided with a Statement of Terms and conditions prior to moving to the home. EVIDENCE: The case files of 4 residents were examined. All had been assessed prior to admission and were given a contract and terms and conditions. A copy of the assessment was held on file. Either the residents or a family member are given a copy of the statement of purpose and there is a copy on display in the home. The pre-inspection questionnaire showed details of the key workers allocated to the individual residents. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The quality in this area is adequate. This judgement has been made using the available evidence including a visit to the service. Care plans are consistent in format but not all those inspected were an accurate reflection of the information shown on the daily record. The home works to an efficient medication policy supported by procedure and practice guidance. EVIDENCE: Case tracking was undertaken in respectof four residents. Care plans and daily records were checked to ensure the care plan reviews agreed with the daily care records. In all but one they did. In the case of one resident, the daily record indicated that the resident required more care than was shown by the care plan monthly review. The daily records evidenced that the healthcare needs of the residents are met by imput from the local healthcare professionals. This was confirmed by discussions with the residents who all agreed that their doctors visited on Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 11 request and the services of the district nurses were available if and when required. Medication records were examined and the inspector dicussed the incident of the missing medication with the acting manager. This incident has now been resolved and has resulted in a new system for the receiving and disposal of medication. This has ensured that more stringent checks are now in place. Residents spoken with, said they felt that they were well cared for and that their privacy and dignity were respected at all times. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The quality in this area is good. This judgement has been made using the available evidence including a visit to the site. The home operates a key worker system, which can enable closer staff and resident relationships. Residents enjoy the flexibility of mealtimes and the opportunity of eating in their rooms if they wish. Regular drinks are available throughout the day. EVIDENCE: All residents are allocated a key worker and the inspector was able to speak with those on duty during the inspection. Interviews with residents and case tracking indicated that the residents were happy with their daily routines and the choices given about how they wished to spend their day. One resident did, however, tell the inspector that she enjoyed a chat but the staff were not often able to spare the time to talk. The home provides some group activities and there are regular outings organised during the summer months. Residents said they could join in the activities if they wished although some of the them who spoke with the inspector said thay also ejoyed the privacy of their own room. All agreed that they enjoyed their food although one resident indicated that sometimes it “depended who was doing the cooking”. In one file there was a Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 13 chart showing daily/weekly intake of food, as the resident was not always inclined to eat. The home currently has no full time chef and are using agency cover, which is not always an ideal situation. Observations during the lunch period indicated that the meals were served and taken in a relaxed manner. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality in this area is good. This judgement has been made using the available evidence including a visit to the service. The home has suitable complaints procedure that is kept up to date. Residents are confident that their views and concerns are listened to. Adult protection training is organised and the staff showed an awareness of adult protection issues. EVIDENCE: The home has a complaints procedure in place with a copy on display in the hall. The record of complaints was checked and the inspector discussed the recent complaint with the acting manager. After investigation, it was found to be partly upheld and new routines for the resident in question have now been put in place. Residents spoken with were confident that any complaints or concers expressed would be taken seriously dealt with as soon as possible. The training matrix indicated that training in elder abuse forms part of the training programme and interviews with the staff indicated that they were aware of adult protection issues. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 & 26 The quality in this area is adequate. This judgement has been made using the available evidence including a visit to the site. The service provides a homely environment but there should be a better programme to improve the internal decoration.Residents can personalise their rooms but they mainly stay in the same communal area during the day. The home is well lit, clean and tidy and smells fresh. EVIDENCE: Discussions with the acting manager confirmed that the plans for internal alterations to the home have been put on hold even though the work was due to start the week following the inspection. This will mean that the extra space allocated for the residents in the dementia care unit will not now be made available, This would have improved the level of care already given and offered more communal space for the residents to enjoy. The alterations would also have meant that the four bedroom currently not used could be made available again. Because of the inpending plans there has been no internal decoration Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 16 within the home, resulting in a building now looking in need of some redecoration. The residents have access to both internal and external space but the perimeter fencing needs attention before residents use the garden during the summer months. All the bedrooms that were inspected were nicely furnished although some were a little on the small side. Residents who spoke to the inspector all said that they were happy with their accomodation. The home was clean and hygienic on the day of the inspection. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality in this area is good. This judgement has been made using the available evidence including a visit to the service. The home uses the corporate recruitment procedure that clearly outlines the process to be followed. The annual staff training programme encourages staff to improve their skills and knowledge. Residents in the home have confidence in the staff to care for them. EVIDENCE: Discussions with the acting manager revealed that all the available staff hours are not currently being used. This has resulted in times when the staffing levels differ during the day, particularly during the afternoon and evening. The inspector examined the staff rota and found that this was so. Extra hours were made available for checking medication and it is important that these continue to be used for the benefit of the residents and the running of the home. The home works to a corporate recruitment policy that ensures all the required checks are completed before any new staff start work. All the staff files checked by the inspector were up to date and contained all the required documentation to meet the standards. The training matrix outlined all the training organised and completed during the last year. The training programme is renewed by Cumbria care each year. Residents told the inspector that the staff were “very caring” and “looked after them really well”. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36 & 38 The quality in this area is good. This judgement has been made using the available evidence including a visit to the site. The acting manager is competent to run the home and ensure it is operated in the best interest of the residents. The home has sound corporate policies and procedures in place that are regularly updated. Financial procedures are in place to guarantee financial viability. The home works to a clear health and safety policy with internal audits undertaken to ensure the standards are met. EVIDENCE: The registered manager has been on long term sick leave since November but is due to return during a phased programme of hours from the beginning of May The acting manager has only been in post since March but discussions with her evidenced that she has worked closely with the supervisors and staff to bring Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 19 all the administrative duties up to date and also to oversee the care of the residents. There is a relaxed atmosphere in the home with residents happy that they can approach any of the senior staff if they have an issue to discuss. All the residents who spoke to the inspector said that Croftside was a nice place to live in and that everyone looked after them very well even when the staff were busy. The financial viability and accounting procedures are in the hands of the organisations head office. Examination of the staff files evidenced that that supervision was, in the main, up to date. Any delays were due to the fact that the home had been without a manager from November last year until March of this year. The pre-inspection questionnaire detailed that all the servicing contracts for equipment are up to date and that regular health and safety checks are undertaken. All the risk assessments were up to date with copies held on the appropriate file. Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X 3 X 3 Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 21 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 Standard OP27 OP19 Regulation 18 16 Requirement Timescale for action 31/08/06 Allocated staff in hours must be filled as soon as possible to avoid the use of agency staff. A programme of redecoration 31/08/06 should be introduced as soon as possible. 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 Refer to Standard OP19 Good Practice Recommendations It is recommended that consideration be given to completing the planned alterations to the ground floor of the building Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 22 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 Croftside DS0000036503.V289150.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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