Inspection on 31/01/06 for Northcroft

This inspection was carried out on 31st January 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Northcroft 17/10/06

Northcroft 03/10/05

Northcroft 10/02/05

Northcroft 18/05/04

Northcroft 19/11/03

Northcroft 23/06/03

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

CARE HOME ADULTS 18-65 Northcroft Barrows Road Cheddar Somerset BS27 3BD Lead Inspector Sally Murphy Unannounced Inspection 31st January 2006 4:30 Northcroft DS0000015982.V281311.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 Northcroft DS0000015982.V281311.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. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Northcroft Address Barrows Road Cheddar Somerset BS27 3BD 01934 744734 NO FAX 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) ORCHARD VALE TRUST MISS CHRISTINE ANN KINGHAM Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Northcroft is a large semi-detached Victorian property situated close to the centre of Cheddar. The home is located within easy access of community facilities. Northcroft is registered with the Commission for Social Care Inspection to provide care for up to eight service users who have a learning disability. All service user rooms are single occupancy and three have en suite facilities. The home has been decorated and furnished to a good standard. There is a garden at the rear of the property that is accessible to service users. The Registered Manager is Miss Christine Kingham. She has many years experience of providing care to adults with a learning disability and has obtained the Registered Managers Award. The Registered Provider is Orchard Vale Trust. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and carried out by one inspector over one day. The previous inspection was also unannounced and took place on 3rd October 2005. On the day of the inspection there were eight service users residing at the home. The Registered Manager was not on duty at the time of the unannounced inspection. During the course of the inspection service users and staff were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: What has improved since the last inspection? There is an ongoing program of re-decoration and refurbishment at the home. The home regularly reviews the service provided to ensure that the support and opportunities offered continue to meet service users needs. Staff and service users from the home will shortly begin rehearsals to perform a play that has been written by the Registered Manager. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 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. Northcroft DS0000015982.V281311.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 Northcroft DS0000015982.V281311.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): 1, 2, 3, 4 & 5. Service users and their families are provided with appropriate information to make a decision regarding admission to the home. The home has developed an appropriate admissions procedure. Service users are provided with a written contract which states the terms and conditions of their stay. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities offered at Northcroft. The home has an Admissions policy. A comprehensive assessment of need is completed prior to any service user moving into the home. Prospective service users are encouraged to spend short periods of time at the home so that they may get to know staff and service users. There have been no new admissions since the last inspection. Service users are provided with a written statement of the terms and conditions of their stay. These were seen within service user plans and had been signed by both parties. Northcroft DS0000015982.V281311.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, 7, 8, 9 & 10. The home has developed an appropriate care plan for each service user. Service users are supported to exercising choice. Care plans are regularly reviewed and updated. Records relating to service users are stored securely. EVIDENCE: Care plans are maintained for each service user. Two care plans were examined in detail. Care plans provide details of service users needs, daily routines and preferences. Service users are able to keep their day-to-day care plans in their rooms and can access any of their other records at their request. Care plans include evidence of service user consultation and promote independence. Risk assessments are completed as required. Care plans are reviewed monthly and updated appropriately. Service users are encouraged to exercise choice regarding their daily routines and social activities. Service users are supported by their key co-ordinators. There is a notice board in the kitchen displaying which members of staff will be on duty. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 10 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): 11, 12, 13, 14, 15, 16 & 17. Service users are able to participate in a wide range of activities, and access facilities within the local community. Service users are supported in developing life skills and are able to maintain contact with family and friends. Service users are provided with a well balanced diet. EVIDENCE: Service users participate in all aspects of running the home, and are supported in developing and maintaining daily living skills. Service users attend work groups at East Court, which is a larger home owned by Orchard Vale Trust. The facilities available at East Court include a bakery, weavery, pottery, vegetable gardens, and batik workshop. Additional workgroups include printing and upholstery / woodwork. Service users are Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 11 also able to attend Further Education Courses held in Adult Community Centres in the area. Service users at Northcroft enjoy trips out to the cinema, bowling or restaurants. Service users from the home are on the committee for the local Gateway Club. One service user attends church each week. Service users stated that they had enjoyed a recent trip to the theatre. Service users are able to choose whether or not to participate in activities, and are able to spend time relaxing in the home within communal rooms or their bedroom. Service users confirmed that friends and family members are made welcome at the home. Service users are involved in choosing and planning trips away from the home. These have included days out, visits to family and holidays in Torquay and Yorkshire. Service users stated that they were starting to plan the trips for the forthcoming year. Service users participate in menu planning and food preparation. Healthy eating is promoted, and fresh produce is used from the large vegetable gardens at East Court. Service users stated that they enjoyed the meals provided. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 12 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. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. All medications are stored securely. The recording of medications was found to follow good practice. EVIDENCE: Service users are provided with support as necessary to undertake personal care tasks. Service users spoke highly of the care offered by staff and confirmed that they are treated with dignity. Service users are assisted in accessing opticians, dentist, and chiropody services as required. A record is maintained of all professional visits. The home has a medications policy. Many of the service users at the home manage their own medication. Risk assessments have been completed as appropriate and secure storage arrangements provided. Medication Administration Records were examined, and found to follow good practice. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 13 The home must review the storage arrangements for medications that require refrigeration. These medications must be stored between 2-8° C. On the day of inspection, the temperature in the medications fridge recorded 15.9° C. Records showed that on the day prior to the inspection a loose tablet that appeared to be Risperdal was found by a staff member. The Registered Manager must ensure that the Inspector receives a copy of the investigation taken into this, and notified of any changes to practice that may be made as a result. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 14 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 & 23. The home has appropriate polices and procedures in place to safeguard vulnerable service users. EVIDENCE: The home has a complaints procedure that provides details of external agencies that may also be contacted, including CSCI. There have been no complaints received by the home or CSCI since the last inspection. The home has appropriate policies relating to the Protection of Vulnerable Adults and whistleblowing. The home consults with other agencies and utilities a robust risk assessment approach to promote the health and safety of service users. Service users confirmed that they would be able to approach the Manager with any issues of concern. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 15 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, 25, 26, 27, 28, 29 & 30. The home has been decorated and furnished to a high standard. There is sufficient communal space and bathing facilities to meet service users’ needs. Service user rooms have been decorated to reflect individuals’ tastes. The home is maintained to a high standard of cleanliness. EVIDENCE: Northcroft is located close to the centre of Cheddar. Communal areas comprise of a large lounge and dining room. All service user rooms are single occupancy and three have en suite facilities. Three service users showed the Inspector their rooms. Service users had been involved in choosing the décor for their rooms. New furniture has been purchased for some areas within the home. The home has been pleasantly decorated and furnished. There are appropriate bathing facilities to meet service users needs. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 16 Two staff provide sleep-in cover each night. Currently there are no separate bathroom facilities for staff. This is currently under review by Orchard Vale Trust. There are no environmental adaptations required at present. The home would seek further advice should the needs of the current service users change. The laundry is tidy and well organised. Service users each wash and iron their clothes with appropriate support from staff members. In order to reduce the risk of cross infection, tablets of soap must not be available in communal bathrooms, and hand washing facilities consisting of liquid soap and paper towels must be provided in the laundry. The home is maintained to a high standard of cleanliness. Northcroft DS0000015982.V281311.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): 31, 32, 33, 35 & 36. Staffing levels are appropriate to meet service users’ needs. Staff offer a high standard of care and are provided with the training required to undertake their role. Staff are provided with appropriate support and supervision. EVIDENCE: Duty rotas are maintained. There are generally two staff on duty throughout day, although this is flexible dependent upon the number of service users at home, and activities planned. Two members of staff provide sleep-in cover. Newly appointed staff are provided with a thorough Induction program. All staff members receive regular updates in mandatory training. The home has recently purchased a training package, which will enable staff to cover a range of courses including fire safety, first aid and infection control. Staff are also encouraged to study for NVQ qualifications in care. Staff meetings are held on a monthly basis. Staff confirmed that they are provided with appropriate support, and receive regular supervision. The Registered Manager and Deputy Manager were not on duty during this or the previous unannounced inspection, therefore recruitment files could not be Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 18 examined. The Inspector was advised that there have been no new staff employed since the last inspection. Northcroft DS0000015982.V281311.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, 38, 39, 40, 41 & 42. The Registered Manager provides effective leadership to the staff team. There is a relaxed and open atmosphere within the home. Records relating to service users are stored securely. Appropriate actions have been taken to promote the health and safety of staff and service users at the home. EVIDENCE: The Registered Manager is Miss Christine Kingham. She is an experienced manager and has obtained the Registered Managers Award. Service user meetings are held each month. Service users confirmed that these were valuable and that their views were listened to. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 20 Regulation 26 visits are completed each month and records maintained. The home displays appropriate Employers Liability insurance. Fire safety records were examined. Fire equipment is serviced and tested as required. Staff are provided with regular fire safety training. Staff are provided with health and safety training. Accidents have been reported and recorded as required. Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 21 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 4 3 3 3 X Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA20 YA30 Regulation 13(2) 13(3) Requirement Medications requiring refrigeration must be stored between 2-8 C. In order to reduce the risk of cross infection, tablets of soap must not be available within communal bathrooms, and hand washing facilities consisting of liquid soap and paper towels must be provided in the laundry. Timescale for action 10/03/06 10/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Northcroft DS0000015982.V281311.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Northcroft DS0000015982.V281311.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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