Inspection on 03/02/06 for Newcroft

This inspection was carried out on 3rd February 2006.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newcroft 23/04/07

Newcroft 15/11/05

Newcroft 28/03/05

Newcroft 28/07/04

Newcroft 03/02/04

Newcroft 26/08/03

Newcroft 12/02/03

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

CARE HOME ADULTS 18-65 Newcroft 1 & 2 Todenham Road Moreton-in-marsh Glos GL56 9NJ Lead Inspector Mr Paul Chapman Unannounced Inspection 3 February 2006 08:45 rd Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 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 Newcroft DS0000016508.V283231.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 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. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Newcroft Address 1 & 2 Todenham Road Moreton-in-marsh Glos GL56 9NJ 01608 652886 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) www.hft.org.uk Home Farm Trust Mrs Denise Mumford Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 LD(E) place for named service user within total registered numbers. This condition to be removed once the service user is no longer accommodated. 1 LD/DE place for named service user within total registered numbers. This condition to be removed once the service user is no longer accommodated. 15th November 2005 Date of last inspection Brief Description of the Service: Newcroft is two semi-detached properties offering accommodation for seven service users, three in one house, and four in the other. The houses were purpose built for this service user group. All of the service users have had comprehensive assessments completed, and these are supported by care plans to meet needs. The home is well decorated, and personalised with service users processions. The service users lead active lives attending work placements, day centres and being involved in various social activities. The home is staffed twenty-four hours a day, seven days a week. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed on a morning in February 2006 and was completed over a period of 2 hours. The inspector met with one staff member and four service users whilst at the home. In addition to this a tour of the communal areas of the premises was completed and service users, medication and other health and safety records were assessed. The main aim of this inspection was to assess the homes’ progress towards meeting the requirements of the previous inspection report and examination of three key standards not assessed on the last occasion. It is recommended that for a more comprehensive overview of the service provided at the home, that this report is read in conjunction with the report for the announced inspection completed on 31/10/05. What the service does well: Comments from the service users about activities, staff and the home were very positive. The home provides a high quality service that is led by the needs of the service users. The Person Centred plans developed with the service users are well designed making good use of pictures and plain English. Evidence in records showed that service users goals were being achieved, or progress towards them was evident. All of the service users lead active lifestyles and staff support them to do this where it is required. The premises are well maintained and has a maintenance programme that is implemented by HFT. Staff complete training in mandatory topics of food hygiene, first aid, etc. They also complete training to meet the specific needs of the service users living in the home. The majority of the staff have completed their NVQ’s. The regular auditing of the policies, procedures and practice ensures that the quality of the service is maintained and improved where appropriate. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 7 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 Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 8 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): EVIDENCE: No new service users have been admitted to the home since the previous inspection. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 9 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, 9 The risk to the service user of injury due to their increased health needs is minimised by a thorough risk assessment that identifies the actions required by staff to reduce the risk. The use of sound monitoring equipment reduces the risk of the service user being injured unknown to the staff but this must not infringe on their privacy. EVIDENCE: Whilst examining some of the service user’s documents the inspector noted that staff are using a sound monitor in their bedroom. This is due to the service user’s deteriorating health. The inspector noted that the guidelines/memo did not state that the monitor should be switched off during the day. This should be added to ensure that the service user’s privacy is not infringed on when they are in their bedroom during the day. This becomes a requirement of this report. A recommendation of the previous inspection was for the manager to complete a risk assessment for one service user whose health is deteriorating and causing an increased risk of them injuring themselves. This risk assessment Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 10 has been completed and the inspector was supplied with a copy of it. The assessment identifies the potential hazards and the required actions to reduce the risk. Another recommendation to the manager was that they obtain a copy of the risk assessment completed by the day service for one of the service users that walks from the day service to their place of work. The service manager said that she had contacted the day service about this document and was awaiting a response. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 11 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): 17 A dietician should be involved where a service user wishes to lose weight ensuring that along with losing weight they are able to maintain the correct daily intake of nutrients. EVIDENCE: At the previous inspection standards 11 to 17 were inspected. One recommendation was made that related to the manager contacting a dietician for one of the service users. The inspector was unable to confirm whether this has been addressed and therefore this recommendation is carried over as part of this report. When the inspector arrived at the home some of the service users had already left to attend their day services whilst others were waiting to leave. The inspector spoke to a number of the service users who all appeared to be happy and looking forward to their planned activities for that day. Another service user spoke about his visit to his family at Christmas. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 12 At the previous inspection service users comments, confirmed by the records available for inspection showed that the service users lead active and varied lifestyles. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 13 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): 19, 20 The guidelines being developed by the home should ensure a consistent approach by the staff team to the service user’s personal care preferences. Medication procedures must be adhered too to ensure that the service users are not put in unnecessary risk of a medication error by staff. EVIDENCE: A requirement of the previous inspection related to standard 19. The manager was required to develop guidelines for one service user’s personal care preferences. The service manager arrived during the inspection and explained that these guidelines are being written at the moment and that they will supply the inspector with a copy of the guidelines when they are complete. The requirement of the previous report gave a timescale for the guidelines to be completed by 24/02/06 and therefore the home are still within this timescale. Medication administration was inspected and some shortfalls were identified. • A sample of medication administration sheets showed two occasions when staff had not signed to confirm the medication had been administered. Staff must ensure that they sign to confirm that medication has been administered. • Topical creams should be dated when they are opened. Three items were found with no dates. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 14 • Staff had used correction fluid to correct an entry on one service user’s medication sheet. If an error is made then staff should follow the medication sheet’s key, and initial any correction. Other areas of the medication administration showed good practice with stock being checked monthly and the pharmacist signing documentation to confirm medication has been disposed of. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 15 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): 23 Training in the prevention from abuse will raise the staffs’ awareness and reduce unnecessary risks to the service users. EVIDENCE: As identified later in this report the service manager has asked the HFT training officer to organise prevention from abuse training for the staff team. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 16 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, 30 The home provides the service users with ample communal space that feels homely as it has been personalised by the people in living there. EVIDENCE: The communal areas of the home were seen during the visit. All areas appeared to be clean, tidy and there were no offensive odours. The communal areas of the home are personalised with the service users interests. Notice boards around the home showed examples of picture job rotas for the service users, a picture staff rota, menus and shopping rota. This is a really good practice and enables the service users to understand what maybe complex documents easily. At the previous inspection the manager said she had requested that a number of maintenance issues around the home were addressed by the provider. These • • • included: Replacing the carpets in the two lounges House one – Fitting a new floor covering in the dining room House two – Decorating the kitchen These areas will be assessed at the next inspection. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 17 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): 33, 35 Training in these two topics will raise the staffs’ awareness and reduce unnecessary risks to the service users. Unnecessary risks to the staff and service users were seen during the inspection by a staff member working alone. EVIDENCE: When the inspector arrived at the home to complete this inspection only one staff member was on duty (the minimum number of staff on duty should be two). The inspector spoke to staff about this. They explained that a relief staff member had phoned in sick at 0715 that morning and they had not called in any extra staff as they felt they were able to manage by themselves. The inspector discussed this matter with the service manager who agreed this was unacceptable and putting the service users and staff member at risk considering the needs of the service users. The manager must ensure that staff are clear that they cannot work alone in the home and that this practice is not repeated in the future. The previous inspection report made a requirement for the staff team to complete training in abuse awareness and manual handling. The staff member on duty said that they had not attended training in abuse awareness or manual handling recently. The service manager explained that they have requested the training officer to organise this training for the team and that it will be Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 18 completed in the next few months. The requirement of the previous report gave a timescale for this to be completed by 26/05/06. As this timescale is yet to expire this requirement is carried over in this inspection report. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 19 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 The home provides a high quality service that meets the needs of the service users currently living there. EVIDENCE: Standards 39 and 42 were assessed at the previous inspection and no shortfalls were identified. Since the previous inspection the registered manager has been off ill for a period of time and the senior support worker has taken responsibility for the management of the home. The inspector feels that the home has continued to provide a high quality service throughout this difficult time. The registered manager has now returned. Newcroft DS0000016508.V283231.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 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 X 2 X 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 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 1 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X 3 X X X X X X Newcroft DS0000016508.V283231.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. Standard YA6 Regulation 12(4)(a) Requirement Timescale for action 24/03/06 2. YA19 12(2, 4), 15 The manager must ensure that the guidelines for the use of the sound monitor clearly state that the monitor must be switched off during the day. The manager must ensure that 24/03/06 where a service user requires staff support to maintain their personal care guidelines are available detailing the service users preferences. No guidelines received by previous timescale of 24/02/06 The manager must ensure that: No gaps are left in the medication administration sheets. That correction fluid is not used on medication sheets. All topical creams are labelled with the date they are opened. The manager must ensure that staff do not work alone in the home in the future. Staff must complete training in abuse awareness and manual DS0000016508.V283231.R01.S.doc 3. YA20 13(2) 31/03/06 4. 5. YA33 YA35 18(1a) 13(5, 6) 24/03/06 26/05/06 Newcroft Version 5.1 Page 22 handling. This requirement is carried over from the previous inspection. 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 YA17 Good Practice Recommendations The manager should seek advise about a service users diet. Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Newcroft DS0000016508.V283231.R01.S.doc Version 5.1 Page 24 - 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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