Inspection on 12/07/05 for Homecroft

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Homecroft 09/06/07

Homecroft 30/08/06

Homecroft 23/01/06

Homecroft 15/02/05

Homecroft 18/05/04

Homecroft 22/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Homecroft 446 Lichfield Road Four Oaks Sutton Coldfield, West Midlands B74 4BL Lead Inspector Karen Thompson Unannounced 12th July 2005 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 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. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Homecroft Address 446 Lichfield Road Four Oaks Sutton Coldfield Birmingham West Midlands, B74 4BL 0121 308 6367 0121 308 8294 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr and Mrs Murch Mrs Marjorie Joan Murch Care Home 19 Category(ies) of Old Age (19) registration, with number of places Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15th February 2005 Brief Description of the Service: Homecroft is a registered care home for 19 eldery people in Sutton Coldfield. It is located on the main Lichfield Road and is on the bus route for Birmingham as well as Lichfield and Burton. It is also within walking distance of Butlers Lane railway station. Homecroft was open in June 2001 on the site of the owners former home and offers modern facilities of a high standard. The home has good furniture and matching throughout. There are seventeen single bedrooms and one double bedroom all have ensuite tiolets and wash hand basins. Some of the bedrooms also have level access shower facilities. There is a vertical lift enabling access to the first floor bedrooms and the assisted bathroom. An assisted shower room is available on the ground floor. Communal rooms on the ground include:- a lounge, a library and dining area, a conservatory. Also located on the ground floor are the kitchen, laundry and an office. At the front of the home there is ramped access to the building and parking for both able and disabled visitors. There is a well appointed garden at the rear which includes lawns, shrubs, patio areas with garden furniture and a small water feature. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over eight hours. This is the first of the statutory inspections for this home for 2005/2006. During the inspection a tour of the premises was made during which some bedrooms were inspected three resident files and other care documentation was inspected. The inspector spoke to both the owners and senior management team and eight of the nineteen service users. What the service does well: What has improved since the last inspection? Regular residents meetings take place providing an opportunity to give active feedback to the homes management team. Staff also have regular team meetings which are used to update them. Small improvements in the management risk such as securing tall furniture had improved safety in the home. Staff rotas clearly identify who is fulfilling each position in the home. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 6 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. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 8 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 standard(s) 3.4 The admission procedure is thorough ensuring that residents are assured that their care needs will be met by the home. EVIDENCE: Three residents files were sampled and there was evidence that the Manager carried out a pre admission assessment for each individual. This assessment is carried out during a day visit, when potential residents are asked to visit the home, the assessments were detailed. The Care manager and staff were able to demonstrate an individual approach to residents and meeting their needs. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 9 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 standard(s) 7.8.9.10 The health needs of Residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Systems in relation to medication need to be more robust to protect the resident. EVIDENCE: Risk assessments were in place and being linked into the care planning process. The Manager had established a falls register, which was identifying risks and action was being taken to reduce this risk. Care plans were being reviewed monthly and resident involvement was evident. Residents are able to access a chiropodist that visits the home. One resident had a pressure relieving mattress in place but the date that this had been put on the resident’s bed and type had not been recorded. The Care Manager receives input from the district nursing service, for residents. The home is advised to record this type of information separately as district nurse records leave the home once care has been discontinued by this service. The majority of medication audits undertaken were correct. Not all staff dispensing medication had attended an accredited medication training course. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 10 The home audits all medication bought into the home but does not sign the MAR record to indicate what quantity has been received. The inspector witnessed good interaction between staff and residents. Residents commented that they were happy with the care provided. The inspector was shown a number of letters from relatives, which were positive in their praise of the care given by the home. All residents bedroom have an appropriate lock in place. The inspector was inform by the Care Manager that residents are offered a key to their room this needs to be documented in their care plan. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 11 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 standard(s) 12.13.15 Residents are helped within the home to exercise choice and control over all aspects of their lives. EVIDENCE: The inspector arrived on the morning that residents had a craft session, residents sell what they make and the profits go towards a charity they have nominated. The residents also have access to a ‘shop’ run by themselves to allow them to purchase personal items. Activity records were kept in regards to residents and indicated a wide range of events taking place. Residents said that they were free to go to bed and get up when they liked and are offered tea in their bedrooms each morning. Residents were observed wandering freely around the home, chatting in small groups and sitting out the garden. Visitors were noted to be around the home during the course of the inspection. The menu indicated that choices offered are varied with the seasons. Residents commented that they had a choice, offered on a daily basis. The lunchtime meal, shared with the residents, was nicely presented and service users in need of support were assisted discreetly. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 12 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 standard(s) 16.18 The complaints and Adult protection procedures could potentially lead to poor outcomes for residents. EVIDENCE: The complaints procedure, which in on display in the reception area, needs to indicate timescales for completion of a complaint. The homes complaint procedure fails to recognise that the CSCI can be contacted at anytime by the complainant. The home has received no complaints since its previous inspection. In relation to adult protection the home did not have a copy of the Multi agency guidelines for Birmingham. Not all staff had received training in relation to adult protection. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 13 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 standard(s) 19.23.24.26. The standard of the environment within the home was good providing residents with a safe, attractive and homely place to live. Resident’s rights to privacy are respected and upheld in the home. EVIDENCE: The home had a good standard of furnishings and fittings in communal areas. All bedrooms have ensuite facilities of a toilet and wash basin, some ensuites also have a level access shower. The home has a communal assisted bath upstairs and a communal assisted shower downstairs. All bedrooms seen were personalised and had a good standard of décor and furnishings. The home was clean, hygienic and odour free. Although the laundry shares a corridor with the kitchen staff practice in the home ensures that laundry and food trolleys are not transported at the same time. The home needs to formalize this in its policies and procedures. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.29 Residents are not fully supported and protected by the home practice in relation to staff working excessive hours. EVIDENCE: The inspector took away 4 weeks of rotas. Staff at the home had multi role that included caring, domestic and laundry tasks. The home has a separate person for catering. One member of staff under the age of 18years was identified to be working at night as the second carer. In discussion with the manager post inspection, she stated that this carer did not partake in any personal care for the service users. Another carer was identified on the rota as working 24 hours in one stretch by working a late, night and then an early. This was not a one off emergency arrangement but planned off duty for the four week period, this is not good practice. The inspector viewed three staff files, one member of staff had no CRB in place as they were under the age of eighteen. References need to state who the person is giving the information and in what capacity they know the applicant. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31.33.35.36.38. The Care Manager was supported by her senior team and provided clear leadership throughout the home. The health safety and welfare of the residents and staff were well maintained with only minimal requirements being made. EVIDENCE: The Care Manager is a registered nurse and states she has completed her Registered Managers Award along with two other members of staff. Also two other members of staff have completed the NVQ 4 in management. The Care Manager along with her husband are owners of the home. The home quality assurance system is evolving. Service users opinions are sought via residents meetings. The home needs to gather residents and relative opinions and ensure this is used to inform the quality audit. The Manager receives no personal allowance for residents but does hold money deposited with her for safe keeping. These moneys are individually kept in Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 16 envelopes with the withdrawals and deposits written on the envelope. The home needs to formalize its record keeping in regards to Residents money. Receipts must also be obtained from chiropodist and hairdressers. The home needs to develop strategies in situations when Residents appear not to be getting any personal allowance. Formal staff supervision was taking place within the home and records were being kept. These need to be taking place six times a year and frequency will be monitored at the next inspection. The home has not recently had a fire drill. The home had reviewed its training procedure following a fire officers visit. Staff had undergone this training but no record could be found. The home must audit staff records to ensure all members of staff have received fire safety training and that this is taking place for each member of staff at least twice a year. Manual handling training is provided in house but this has not been formalized in staff files as taking place. The Commission had not received notice via Regulation 37 of incidents such as fall that had occurred in the home. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 3 x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 3 x 2 x 2 x x 2 Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 18 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. Standard 7 Regulation 15(1) Requirement the Registered Person must ensure that care plans clearly state how service users pressure care needs are being met including type of pressure relief equipement being used. The Registered Persopn must ensure that multidisciplinary input is recorded in the service users care plan. The Registered Person must ensure all Medication Administrtion Records (MAR) have the amount of medication brought into the home recorded on them. The Registered Person must ensure that all staff administering medication have received accredited training. The Registered Person must ensure that the Complaints procedure is simple and clear to support the home to ensure that complaints are dealt with promptly and effectively The Registered Person must ensure that all staff are trained in relation to adult protection and they clearly understand there role Timescale for action 30th July 2005 2. 8 15(1) 30th Sep 2005 30th July 2005 3. 9 13(2) 4. 9 13(2) 30th Sep 2005 30th July 2005 5. 16 22 6. 18 13(6) 30th Seo 2005 Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 19 7. 19 13(6) 8. 26 13(3)(4) The Registered Person must ensure that they have a copy of the Birmingham Multiagency guidelines and that this is incorporated into their adult protection policy and procedure and staff are familiazed with it. The Registered Person must ensure that policies and procedures are in place with regards to the shared corridor for kitchen and Laundry in regards to traffic policy. 30th Sep 2005 30th Sep 2005 9. 10. 11. 30 & 38 19 Sch 2(4) The Registered Person must ensure that staff files evidence training and that all staff receive the required training within the target time limits. Outstanding requirement from 15th Feb 2005 The Registered Person must ensure that staff are not rota to work planned excessive hours. The Registered Person must ensure that the quality assurance programme provides opportunities for comments and complaints from the service users, their families and staff to be sought. The Registered Person must ensure that records in respect of money held on behalf of residents includes details of transactions together with receipts for purchases made. The Registered Person must retain evidence of a fire drill at least six monthly with the names of staff who attended. Outstanding requirement from 15th Feb 2005 The Registered Person must ensure that the Commission is notified without delay of any 30th Sep 2005 12. 13. 27 33 18(1)(a) 24(1)(3) 30th Aug 2005 30th Sept 2005 14. 35 15. 38 23(4)(e) 16. 38 37 30th Aug 2005 Page 20 Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 event or occurance within the home as detailed in the regulations. 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 26 35 Good Practice Recommendations The Registered Person should contact the Health Protection Unit at Bartholew House, Hagley Road, Birmingham to carry out an environmental audit. Tel. 0121 224 4670. It is recommended that the home developes strategies to manage when service users appear not to be in receipt of any personal allowance.. Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Homecroft E54 S16760 V23653 - Homecroft 120705 - Stage 4.doc Version 1.40 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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