Inspection on 10/07/07 for The Croft

This inspection was carried out on 10th July 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Croft 14/08/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Croft Thorrington Road Great Bentley Colchester Essex CO7 8PR Lead Inspector Jane Greaves Key Unannounced Inspection 11th July 2007 09:00 The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Address Thorrington Road Great Bentley Colchester Essex CO7 8PR 01206 251904 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) Mr Ramoo Sunnassee Mr Ian J Thomas, Mrs Selimah Thomas, Mr Yoosoof Morowa Mrs Selimah Thomas Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) Mr Sunnassee will not have any part in the day to day running of the home 14th August 2006 Date of last inspection Brief Description of the Service: The Croft is a large detached bungalow located in the pretty Essex village of Great Bentley. The home provides care and accommodation to 6 service users with learning disabilities. The roof space has been converted to provide an office, laundry facilities and staff facilities. The bungalow has a large well maintained rear garden that backs on to fields with a substantial vegetable plot and barbecue area. There is some ‘off street’ parking to the front of the property. There is an outdoor swimming pool that is currently fenced off for safety reasons and this area is currently under consideration to extend the premises. Charges levied for the care and accommodation provided at the Croft range from £631 - £672 per week, items such as hairdressing, chiropody and aromatherapist are extra costs. Inspection reports published by the Commission for Social Care Inspection were available from the manager on request. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, covering the key National Minimum Standards and the intended outcomes of these, took into account all the information the Commission for Social Care Inspection had received about The Croft since the last inspection. An unannounced visit to the home took place on 10th July 2007 lasting 4 hours. The inspection process involved: • • • • • • • Speaking with people living and working at the home Speaking with the person in charge Gathering views of family members, healthcare professionals and other community stakeholders via means of surveys. Speaking with family members over the telephone Looking all round the home Observing how people were supported Sampling records. Some shortfalls were identified resulting in 1 requirement. What the service does well: What has improved since the last inspection? Since the last visit to this service the manager has completed her Registered Manager’s Award. The care plans have been developed, are in a clearer format The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 6 and provided evidence that family members are involved in the care and review of the care of their relatives. Alterations are being made to the building to make shared rooms into single rooms to provide more privacy for the people living there. 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. The summary of this inspection report can be made available in other formats on request. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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 The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering making The Croft their permanent home have access to all the information they need to make an informed decision. EVIDENCE: There have not been any new admissions to The Croft since the previous inspection visit. The home has an up to date Statement of Purpose and Service User Guide that have recently been altered to reflect the service and facilities provided, some minor alterations to the content of these documents were discussed with the registered manager. The home has developed a brochure that gives a brief outline of the services provided at The Croft for visitors and healthcare professionals to take away with them. It was reported that trial visits would be offered to people considering making The Croft their permanent home for example overnight stays and weekend visits. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supported and encouraged individuals to make choices as much as their disabilities allowed EVIDENCE: The people living at The Croft do not sufficient cognitive awareness to make conscious decisions; the registered manager reported that decisions affecting their health, safety, well-being and lifestyles were made on their behalf by the home in conjunction with family/representative where appropriate. The manager was able to describe instances where families had been involved in decision-making processes and there was documentary evidence to confirm this. The care plans are individualised and look at all areas of people’s lives. A key worker system is in place in the home. Care plans are reviewed monthly and changes necessary to meet individuals’ needs were documented accordingly. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 10 Care plans included risk assessments relating to issues relevant to individuals such as weight gain, accessing the community, skin care and nutrition. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home understands the importance of enabling the people living there to achieve their personal goals. EVIDENCE: The people living at The Croft were encouraged and supported to maintain important personal and family relationships. Family members were involved in helping the home select activities, pastimes and outings for individuals. People are involved in daytime activities according to their individual interests and abilities. Where appropriate, education opportunities are encouraged, supported and promoted. The registered manager reported how one person had been to college before entering the home on a permanent basis but had discontinued to do so. The home supported this person to visit the local college and enrol in various courses such as drama, singing and communication. The home was supporting one person to recognise coins and the relevant values in The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 12 order that they can become more actively involved in shopping for their personal items. One individual visited a day centre weekly and enjoyed activities such as games, watching television, barbecues, darts and skittles. Two people went to a club where they attended discos, parties and other social gatherings. Four individuals had enjoyed a shopping trip to France and the home had hosted a big party to celebrate on individual’s ‘milestone’ birthday where family members attended. Activities that take place within the home vary according to individuals’ needs and abilities. One person helps to do minor household chores and assists in the garden in fine weather. Others enjoy pastimes such as listening to music, doing exercises to music, playing ball, doing puzzles, having staff read to them, watching films and sitting in the garden. Routines of daily living are flexible around individuals. It was reported that whoever is awake first is assisted to wash and dress first. The registered manager reported “if there is any sign of resistance to getting out of bed, we leave them to have a lie in”. The same as going to bed at night, some people like to watch television quite late in the evening where others like to go to bed earlier. Relatives are involved in discussion around daily routines for those individuals unable to communicate their wishes. The registered manager reported, “We have learnt through trial and error what each person living at the home likes to do, eat and what clothes they like to wear”. Main meals are scheduled at specific times to provide a feeling of normality and security however when people had activities outside the home their meal times were flexibly arranged around them. The home provided a nutritious, varied and appetising diet. Food hygiene training had been provided for all staff members. The kitchen was in good repair and adequate food stocks were maintained. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. EVIDENCE: Personal healthcare needs are recorded in each person’s plan. A discussion was held with the registered manager around providing more detail about how individual support is to be provided for example one plan sampled stated: ‘Provide shower or wash as preferred’ but no detail was available about specific support required by the person to take the shower. Care plans addressed all areas of assessed need such as eating, skin problems, mobility, continence, personal hygiene and communication. Other information contained within care plans included, next of kin contact information, individual’s exercise programmes, likes and dislikes, any infringements of rights, dietary requirements, weight records and a list of medications. An inventory of personal items brought into the home by individuals and purchased subsequently for them was maintained separately from the care plan in an individual book for each person living at the home. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 14 The service ensures that routine healthcare appointments such as chiropodist, GP, Dentist, Optician and audiologist take place; these are recorded within individuals’ care plans. The registered manager provided a letter from the chiropodist that attended the people living at The Croft that said: “The impression I always get is of warmth and care and I can only compliment the staff on the attention they give to the residents.” No person living at the home was able to self medicate. All the staff team had received training in the safer administration of medicines. Medication was stored appropriately in a locked cupboard secured to the wall of the office. Medication Administration records were maintained appropriately. The manager reported the GP undertook regular six monthly reviews of individuals’ medications. The home had not had a pharmacy audit since the previous visit however the registered manager reported that one was due imminently. Family members were pleased with the care and support afforded to their relatives at the home, one person said: “It is always gratifying to see how well xxx is looked after by you and your staff. xxx is always so cheerful when I visit and I am sure that this is a reflection of the friendly environment in which xxx resides.” The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 23 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at the Croft and their families/representatives could be confident that if they raised any concerns or complaints they would be taken seriously and investigated fully. EVIDENCE: The home has not received any complaints since the previous visit. Complaints policy and procedure was seen at this visit. A discussion was held with the registered manager about changing the contact details of the Commission for Social Care Inspection as the document still referred to the National Care Standards Commission. One concern had been raised with the commission since the last visit to the service. This was shared with the management of the home however could not be substantiated. All relatives and representatives have been given a copy of the complaints policy and procedures. All people working at the home had received training in the Protection of Vulnerable Adults and refresher courses had been booked. Evidence was presented by means of the staff training matrix. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at The Croft benefit from a comfortable and homely environment. EVIDENCE: A physical tour of the building was undertaken as part of this visit. The home was clean with no unpleasant odours and was comfortable light and airy. Considerable work has been undertaken at the home including alteration of the lounge diner into two single bedrooms making the existing double bedroom into a lounge diner. This is insufficient space for this purpose, further plans to extend this space to make a large and airy ‘L’ shaped lounge diner are in place, the registered providers reported that this work would be completed by the year end at the latest. A discussion took place around developing risk assessments to promote the safety and well being of the people living at The Croft during the time building works are taking place. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 17 The two new bedrooms have been carpeted, curtained and decorated. Washbasins had been installed in both rooms. The walk in shower has been completed and a new ‘user friendly’ bath has been installed. All fire doors have replaced since the previous visit and a fire sensor sited in the laundry room. Electrical work has taken place to replace and re position plug sockets. The Laundry room has new windows and a replacement ceiling. The old conservatory had damp problems and has been replaced. A letter received by the home from one person’s family said: “xxxx’s new bedroom is fantastic, so much more space for xxx. You have done marvels with all of the new improvements at The Croft” The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 24 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff working at Croft are trained, skilled, experienced and in sufficient numbers to support the people who live at the home. EVIDENCE: Of the nine staff members delivering care at The Croft, 4 had achieved a minimum of NVQ level 2 and one further person had started to work towards this qualification. There were no staff working at the home that had been recruited since the previous visit. The policies and procedures that passed inspection at the previous visit were still in place. The service had a training and development programme covering all the training needs of the home to ensure the health safety and wellbeing of the people living there. A training matrix provided information to demonstrate when staff had attended training such as moving and handling, infection control, first aid, health and safety, medicines and Protection of Vulnerable The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 19 Adults. Epilepsy awareness training had been booked for one staff member and a further staff member has been booked for Makaton training. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect EVIDENCE: The registered manager had the relevant experience to run the home and had achieved the Registered Managers’ Award. Training necessary to protect and promote the health, safety and welfare of the people living at the home and refresher courses were attended alongside the staff team. The home undertook an annual quality assurance survey gathering views of the people living at the home, their families and representatives, healthcare professionals and other stakeholders. This years survey had taken place however a summary of the responses received and the resulting action plan to resolve any identified shortfalls had not been forwarded to the commission. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 21 The home has a consistent record of meeting relevant health and safety requirements and legislation. Certificates were available for inspection to confirm that routine inspections of electrical, gas and fire alarm systems had taken place. The staff team had received training in health and safety, control of infection, Protection of Vulnerable Adults, safer administration of medicines, moving and handling, and first aid in order to protect the health, safety and well being of the people living at the home. The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 22 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 23 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 YA39 Regulation 24 Requirement The person in charge must make a summary of the annual review of care provided at the home and supply this to the commission. A copy of the report must be available to the families and representatives of the people living at the home. This is a repeat requirement that was not met within the original agreed timescale of 30/11/06 Timescale for action 31/12/07 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 The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 The Croft DS0000063989.V345720.R01.S.doc Version 5.2 Page 25 - 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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