Inspection on 14/01/08 for The Croft

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Croft 12/01/09

The Croft 27/11/06

The Croft 19/04/06

The Croft 27/01/06

The Croft 26/07/05

The Croft 07/03/05

The Croft 16/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Croft Barracks Road Bickershaw Wigan Greater Manchester WN2 5PR Lead Inspector Lucy Burgess Unannounced Inspection 09:30 14 January 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Croft DS0000038461.V337346.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 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. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Croft Address Barracks Road Bickershaw Wigan Greater Manchester WN2 5PR 01942 867186 01942 867386 k.idle@ntlworld.com thecroftcarehome@tiscali.co.uk Mr Kevin Harper 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) Mrs Karen Idle Care Home 23 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (17), Old age, not falling within any other of places category (23), Physical disability over 65 years of age (1) The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 23 service users to include: • Up to 23 service users in the category of OP (Older People). • Up to 17 service users in the category of DE(E) (Dementia over 65 years of age) • Up to 1 service users in the category of PD(E) (Physical Disabilities over 65 years of age) One named service user in the category of DE (E) (Dementia under 65 years of age) may be accommodated within the overall number of registered places. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 27th November 2006 Date of last inspection Brief Description of the Service: The Croft Care Home is located in semi-rural surroundings just off the main road through the village of Bickershaw, and provides residential care and accommodation for up to 23 male and female service users of retirement age. The Homes registration also permits them to accommodate a service user with a physical disability and 17 with a diagnosis of dementia. Nursing care is not provided at this Home. At the time of this report, the scale of fees for this home is from £350.00 to £530.00 depending on funding arrangements. There is also a nightly rate for respite stays at £96.00 per night. The fees include all costs with the exception of hairdressing, for which the visiting hairdresser makes a small charge. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was the annual key inspection for the home, which included a site visit and took place over one day, for a period of 7½ hours. The service did not know that the inspector was to visit. During the inspection care and medication records were looked at as well as information about the staff and health and safety including how the home and the equipment were kept safe. The inspector also looked around the building to check if it was clean and well decorated. Time was also spent talking with residents, staff and a relative. Discussion and feedback was also held with the Registered Manager. As part of the inspection process the provider’s are asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was sent to the home before the inspection, had been completed by the manager and returned to us prior to the site visit. Other information was gathered from the feedback surveys we sent out. We received a very good response with completed surveys being returned from 4 relatives and 8 from residents. Comments have been added to the report. None of the staff surveys were returned. The purpose of this visit was to look at the key standards as well as progress made since our last visit. What the service does well: Overall the staff team has remained stable. Team members are clear about what they are expected to do and appear to work well together. Relatives expressed, ‘I think all the care staff do an excellent job’, ‘improvements have been made this year with the new manager and the staff seem more professional in their approach to residents’, ‘we are always kept informed’, ‘I have never felt more settled than I do here’ and the whole staff team work very hard to ensure all residents are well looked after and their needs are taken care of’. Staff have received training in areas which they need to ensure that residents are looked after safely. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 6 From watching staff and residents, it was clear that people are treated in a dignified manner. Residents appeared well, were appropriately dressed. Staff interacted well with residents, they were respectful and patient. What has improved since the last inspection? What they could do better: One area of risk was identified with regards to a resident’s bedroom door being locked. The manager needs to explore this and ensure that assessments and agreements are in place ensuring people are safe and care is not compromised. The manager is asked to provide up to date copies of the homes staff rotas, menus and the recent pharmacy audit. Once updated we would like a copy of the homes statement of purpose and service user guide. An action plan with regards to the refurbishment and redecoration of the home and how this is to be managed, needs to be produced, ensuring residents are disrupted as little as possible. Improvements are needed with regards to the efficiency of the gas appliances and an up to date check of the electric circuits. Whilst it is acknowledge these are to be addressed as part of the refurbishment, should this take too much longer interim arrangements will need to be made to ensure that the systems are safe and do not place people at risk. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 7 When recruiting new staff the manager must ensure that all information in relation to the employment history is detailed on file and that a POVA 1st check or CRB is in place before they commence their employment. The manager is currently in the process of carrying out a quality review of the service provided at The Croft, once all the information has been obtained a report will be developed outlining her findings. She is asked to send us a copy of this report as well as making it available to others involved with the service. We must be informed of all incidents, which may affect the well being of residents in line with regulation. 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 DS0000038461.V337346.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available advising people about what is provided at the home. Those people considering living at The Croft have their needs assessed prior to an agreement being made ensuring their needs can be met. EVIDENCE: Since our last visit there has been a new manager approved by us as the registered manager for the home. The statement of purpose and service user guide have yet to be reviewed and updated. Information is also to be provided in different formats such as Braille and on a computer disk. The manager is asked to forward a copy of each of the documents once they have been amended. The home has an assessment document, which is completed for all prospective residents. Additional information is also sought from the social worker team for those people who are funded by the local authority, however this was said The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 10 to be received following admission being made. Information seen within the care files included assessment information, which the home had sought from the person moving into the home and their relatives. Details were recorded with regards to personal information and contact details, people’s identified support needs, preferred routines and wishes as well as information about their diet and medication. Where possible information was also requested from the funding authority. This information was used to inform the development of the care plan. As the home is registered to provide care and support for older people and those with dementia care needs staff have received training in these areas with further training identified for the forthcoming year. One relative spoken with said that they had spent a lot of time looking at various homes for their relative. They felt that the manager and staff had ‘been marvellous’ in helping him to settle his relative into the home and that there had been ‘considerable improvements’ in their health and well being. Other comments made within the feedback surveys were; ‘an individual approach is used on all the residents’ and ‘I’ve never felt more settled than I do now’. Standard 6 does not apply to the home as they do not provide intermediate care service. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Detailed information is recorded with regards to support and care needs of residents however risks in relation to restraint need to reviewed ensuring this is in the best interests of the individual and their safety is not compromised. EVIDENCE: Care files were looked for four residents with varying care and support needs. Information included personal details, their preferred name by which they would like to addressed, their routine, what support they would need in relation to meeting their personal care needs, assistance with medication, social activities and contact with family and friends, health history and likes and dislikes. Records had been signed and dated by staff and where possible by the resident. Information had been reviewed on a regular basis. The staff also look at whether or not there are any risk in relation to the residents moving and handling including any aids required, falls and personal care. Regular checks were also made with regards to a persons weight so that advice can be sought if an issue or concern is found. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 12 Where needs are identified in relation to a persons diet or pressure care an assessment is then undertaken by the district nurse or dietician and guidance for staff is then added to the care plan so that staff are clear about what intervention is required. Charts are also completed in relation to fluid intake, turning and diet received as well as increased weight monitoring. Another issue was identified with regards to risks. This was in relation to one a resident’s door being locked from the outside whilst in her room. This was said to be due to the behaviours of other residents who may wander into the room and that the family had expressed their concerns. Advice has been sought from the fire officer with regards to this matter. Whilst it is acknowledged the concerns raised by family these arrangements clearly restrict the resident’s freedom to move around the home freely as well as responses in the event of an emergency. Consideration also needs to be given with regards to other residents who may wander and what support is in place to minimise this, therefore reducing the risk to others. The manager is referred to Regulation 13(7) with regards to such restraint. Information needs to evidence that this is the only reasonable way of ensuring the safety of the resident and that a detailed risk assessment has been completed along with agreements made with all relevant personnel. These documents must be placed on file. A copy of such information must also be forwarded so CSCI. All residents are registered with a GP and have access to other health care professionals where necessary such as opticians, chiropody and incontinence advisor. The district nurse team regularly visit the home to support those resident’s with additional health care needs. Staff at the home are to receive some training from the nursing team in relation to pressure care and diabetes so that they have the knowledge and skills needed to meet people needs. Staff support is provided should a resident need escorting to hospital or when attending appointments however agreements have been made with family members with regards to what arrangements or involvement they would like should this arise. Information is recorded on file for staff to refer to. Additional records are also held in relation to personal belongings, room inventories, personal correspondence, hospital admission form and agreements for keys and safe storage of personal items. The home has also introduced individual reminiscence books, which are slowly being completed with residents. These will include photographs, things from childhood or about their family, information about outings or activities and appointments they have attended. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 13 Comments from residents and relatives included, ‘I think the staff cope very well indeed, ‘I think all the care staff do an excellent job’, ‘improvements have been made this year with the new manager and the staff seem more professional in their approach to residents’, ‘we are always kept informed’, ‘I have never felt more settled than I do here’ and the whole staff team work very hard to ensure all residents are well looked after and their needs are taken care of’. The medication system was also looked at. Only designated trained staff administer medication to residents. Items are stored safely and are held in a separate room. A secure cabinet and register is in place for controlled drugs. At present there are none required. Medication is provided by Boots pharmacy and a recent audit has been undertaken by the supplying pharmacy. A copy of the report is to be forwarded to us. Records are maintained with regards to items brought into the home and those returned at the end of each month. Stocks appeared to be well managed. A separate fridge is available should this be required, this is lockable and temperature checks are made. Administration records were also looked at. A photograph of each resident is held with the record. Staff had signed to evidence that medication had been given. A recommendation is made in relation to hand written entries being double signed ensuring the information recorded reflects that on the prescription. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a choice of activities offering stimulation and variety to each day. The dietary needs of the residents are also catered for. EVIDENCE: We carried out a thematic inspection in September 2007. This is a short, focused inspection that looks in detail at a specific area. We looked at the quality of care for people with dementia living in care homes, focussing on ‘dignity’ as an important part of people’s quality of life. Standards 12 and 14 were looked at and our findings were that residents were being supported to follow a lifestyle of their choosing by trained and competent staff. On the day of this visit people were seen to be following routines of their choosing. Some people preferred to spend time relaxing in their own rooms, watching television or reading whilst others spent time in one of the lounge areas. Activities continue to be provided both on a group and individual basis. Holy communion is held at the home for those who wish to observe. There is a designated staff member who will co-ordinate activities with additional support The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 15 from the staff team. One relative stated, ‘they do a lot of 1-2-1 and that keeps them occupied’. Visitors are also welcome at any time and are able to see relatives in private or in one of the communal areas. There is also a hairdresser who visits the home on a regular basis. The Inspector did not have a meal with the residents. The main meal is served at lunchtime, which was sausage casserole or breaded chicken, potatoes and vegetables followed by cheesecake. For tea there was a selection of sandwiches with desert. Alternatives would be provided for those on special diets. There are two dining rooms, which residents can choose to sit for their meal. The eight residents who returned feedback surveys answered ‘usually’ to the question ‘do you like the meals at the home’. The kitchen area and stocks were looked at. Records are completed with regards to safety checks, temperatures and cleaning. Information is also available with regards to ‘safe food better business’ as recommended by the food hygiene inspector. During the visit the food hygiene officer also visited the home. The manager stated that no issues were identified. Food stocks are ordered from a local supermarket on a regular basis. This was said to be better for stock control with items being used throughout the week ready for the next order. The kitchen was clean and tidy with adequate hand washing facilities. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place with regards to responding to complaints and concerns as well as staff training ensuring residents are protected. EVIDENCE: Policies and procedures are in place with regards to complaints and protection. Details are contained with the documents provided to both residents and staff. No complaints were identified. No issues have been raised with us. The manager is aware of her responsibility in relation to safeguarding and who to contact within the local authority should any concerns arise. One issues was identified on the AQAA in relation to safeguarding. This was discussed with the manager and found to be in relation to a resident’s family and not in relation to the home. Staff also receive training in adult protection. Relatives and residents were asked to comment in the feedback surveys about whether they were aware of how to complain and if they felt any issues would be addressed appropriately. Those who responded were aware of how to make a complaint should they need to. One relative also stated, ‘they always try to resolve issues to the best of their abilities’. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Croft provides a clean comfortable, homely environment for the residents. Further redecoration, refurbishment and maintenance of the gas and electric need to be addressed to enhance the environment further as well as ensure people living at the home are safe. EVIDENCE: Changes are planned to the home with occupancy levels to increase to 46 people. At present the plans have been submitted to planning for approval. This will involve demolishing one side of the building, which will then be replaced by a two storey building, providing a further 23 bedrooms and additional communal and bathing areas. The provider and manager are asked to provide us with a plan of the work to be carried out outlining how this will be managed with the minimum disruption The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 18 to residents living at the home. Application will also be required to vary the current registration. Time was spent looking around the home. Some areas have been redecorated, which was said to have improved the appearance of the home. Further improvements are still needed. This will be addressed as part of the refurbishment planned. There are several lounge and dining rooms, where residents are able to sit and relax. Those wishing to are able to relax in there own rooms. There is also a designated smoking lounge available for residents. The manager has sought advise in relation to the suitability of the room. Bedrooms had been personalised with peoples personal belongings brought from home. Toilets are situated close to the lounge and dining areas and are clearly marked. Assisted bathing and shower facilities are also provided. Eleven of the bedrooms also have en suite facilities. Aids and adaptations are provided with grab rails in most corridors. These have been colour coded to make it easier for residents in getting around the home. A new call bell system has also been installed. The residents can lock their rooms and this was observed on the day of the visit. Further issues have also been recorded under conduct of the home in relation to health and safety including the electric circuits and gas services. Servicing and improvements are required to ensure that rooms are appropriately heated, water temperatures are appropriately regulated and systems are safe ensuring the safety or residents and staff. One relative expressed that they had spoken with the handyman on a few occasions due to their relative not having sufficient heating in the bedroom. The home has a separate laundry. The washing machines have the specified programming ability to meet disinfection standards. The staff were observed to wear protective aprons and gloves for specific tasks. The home appeared to be clean and tidy and free from odour other than one bedroom, which the manager was aware of. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained and supported in carrying out their duties however information and checks required in relation to recruitment must be in place prior to them starting work so that residents are not placed at risk. EVIDENCE: Staffing rotas were looked at. The team comprises of the manager, deputy manager, administrator, care staff, a handyman, catering and kitchen staff, domestics and activity worker. Since the last visit all staff vacancies have been recruited for. Cover is provided throughout the day by 4 staff with 3 staff available at night, this excludes the manager and ancillary staff therefore allowing time to support people to appointments or 1-2-1 activities. No agency staff are used. Staff recruitment files were looked at for 5 staff that commenced employment following the last inspection. Information included; application form, health declaration, copies of identification, contracts and references. However shortfalls were found with regards to staff commencing their employment prior to the POVA 1st check being received. One file did not contain a full employment history and another file only had references, which had been taken over the telephone. The manager must ensure that full details The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 20 are provided, along with written references from referees and that staff do not start work until the POVA 1st has been received. At which stage they are able to commence their induction and work whilst being supervised by an experienced member of staff. Training is accessed via Wigan Local Authority Training Department. A staff training matrix is in place which details courses completed and dates when refreshers/updates are required along with copies of certificates. Courses provided over the lat year have included, continence care, food hygiene, first aid, medication, adult protection and mental capacity act. Further sessions are planned covering moving and handling and food hygiene. District nurses are also to provide training for staff with regards to pressure care and diabetes. NVQ training is also undertaken by staff. The majority of carers have achieved level 2 or above. The deputy manager is currently undertaking level 3 in management. A comprehensive induction is carried out with new staff in line with the standard as well as an introductory handbook, which is used to help introduce new workers to the home. This is carried out with a mentor who will offer further support and guidance. From observations made staff interacted well with residents, they were respectful and patient. One relative also commented, ‘staff have right skills and experience to meet the different needs of the people living here’. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team in now established and looks at ways in which the service can be improved for those people living at the home however improvements are needed to ensure that health and safety issues are addressed so that people are kept safe. EVIDENCE: The manager has now been in post for almost 18 months and was approved by us as the registered manager in January 2007. She has previous experience of managing a care home and many years experience of working in the caring profession. Training has also been completed in relation to NVQ at Level 4 and the Registered Managers Award as well as further qualifications in medication and dementia care. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 22 The manager appears to have settled well and is clear about the aims of the home and what needs to be achieved to ensure good outcomes for the residents living at the home. She is also fully supported in her role by the Provider. Comments were received from staff and relatives in relation to the management of the home. All felt that there had been improvements over the last 12 months and that should issues arise these would now be dealt with. In relation to quality assurance the provider continues to carry out the monthly monitoring visits and copies of his reports are provided. Opportunities for relatives and residents to have their say are also provided with periodic meetings. One relative however felt these could be more frequent so that issues could be discussed on a regular basis. Staff also receive training and team meetings where information and ideas can be shared. Feedback surveys have recently been distributed to healthcare professionals, relatives and staff for their comment about the quality of service provided and whether they feel further improvements can be made. Quality reviews are also carried by the manager and relevant staff in relation to specific areas of the home such as maintenance, kitchen, laundry, domestic duties and medication. These are used to identify if any areas need further attention along with any action to be taken. Once all the information has been gathered the manager is to develop an annual report outlining the findings. She is asked to forward a copy of the report to us. The home also paid for an assessment to be carried out by an external quality audit group in September 2007, outcomes within the report were good in relation to the care and supported provided for residents. In relation to finances, the home only provides support to residents with regards to their personal allowances. The local authority provides money and records are maintained showing what has been received and what has been provided to the resident with records being signed by both staff and the resident. Family assists all other residents. Staff supervision and appraisals are carried out on a regular basis. This includes 4 supervisions sessions and 2 appraisals each year. Individual records are made. In relation to health and safety the home employs a handyman who works at the home 3 days a week as well as being on-call should an emergency arise. The inspector spent time talking with the handyman about his role and looked at records in relation to the checks made, this includes water temperatures, fire safety, call bells and general repairs. The call bell system has recently been updated. Information was orderly and up to date. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 23 Annual checks are also made by outside contractors with regards to the electric, gas supply, fire alarm and equipment, hoists, legionella and small appliances. The handyman has recently completed training with regards to the testing of appliances and is awaiting delivery of the equipment. It will be his responsibility in future to carry out such checks. It was noted that the 5-year electrical check had not been undertaken. A letter dated August 2007 was held on file from the provider stating that agreement had been made to extend the current certificate for 12 months pending the refurbishment planned for the home. Should progress not be made in the areas within the near future, interim arrangements must be made to ensure the system is safe. There was also issues identified with the gas boilers, which were effecting the efficiency of the heating system and water temperatures. Again these are to be replaced as part of the refurbishment with an external boiler room to be provided. Information must be forwarded to us identifying when the work is to commence along with timescales for completion. Should the refurbishment be delayed action must be taken by the provider to ensure that systems within the home are working effective and do not place people at risk. During the visit the food hygiene officer also inspected the home. The manager stated that no issues were identified. The fire officer last inspected the home in April 2007 and an up to date fire risk assessment is in place. Records are maintained in relation to accident and incidents. Information provided by the manager did not correspond with the information sent to us in line with regulation 37. It was found that initially incidents involving residents whilst in hospital had not been reported however the manager is aware that this information is required. The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 25 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. Standard OP7 Regulation 13(7) Requirement The manager is referred to the Regulation with regards to restraint. Information needs to evidence that this is the only reasonable way of ensuring the safety of the resident and that a detailed risk assessment has been completed along with agreements made with all relevant personnel. These documents must be placed on file. A copy of such information must also be forwarded so CSCI. Timescale for action 28/02/08 2. OP19 OP25 23 A plan of work (and how the registered provider intends to minimise disruption to residents) and timescales for completion should be forwarded to CSCI. A detailed employment history and POVA 1st/CRB checks must be held on file before new staff commence work ensuring residents are protected. 30/03/08 3. OP29 19 schedule 2 28/02/08 The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 26 4. OP38 23 (2) Action must be taken by the provider to ensure that systems within the home (gas heating and electric circuit) are working effectively and do not place people at risk. 30/03/08 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. 3. Refer to Standard OP1 OP9 Good Practice Recommendations Once amended a copy of the home statement of purpose and service user guide should be forwarded to CSCI. A copy of the recent pharmacy audit should be forwarded to CSCI. Hand written entries on the medication administration records should be double signed ensuring the information recorded is accurate and reflects that detailed on the prescription. A copy of the homes menus are to be forwarded to CSCI. A copy of the staff rotas are to be forwarded to the CSCI. These should include both care and ancillary staff. All incidents, which may affect the well being of residents must be reported to the CSCI in line with the regulation. OP9 4. 5. 6. OP15 OP27 OP38 The Croft DS0000038461.V337346.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. 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