Inspection on 20/05/05 for The Croft Rest Home

This inspection was carried out on 20th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Croft Rest Home 28/05/08

The Croft Rest Home 24/05/07

The Croft Rest Home 30/01/07

The Croft Rest Home 26/04/06

The Croft Rest Home 28/11/05

The Croft Rest Home 09/12/04

The Croft Rest Home 15/04/04

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 84 King Street Whalley Lancashire BB7 9SN Lead Inspector Lynn Mitton Unannounced 20 May 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service The Croft Rest Home Address 84 King Street Whalley Lancashire BB7 9SN 01254 822821 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Lancashire Nursing and Residential Homes CRH 26 Category(ies) of Old age, not falling within any other category registration, with number (OP) 26 of places The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered provider should at all times, employ a suitably qualified and experienced manager, who is registerd with the Commission for Social Care Inspection. 2 The registered manager must attain the Registered Managers Award, in addition to the National Vocational Qualification in Care at Level 4. 3 The home can accommodate up to 26 persons in the category of OP who require personal care. 4 When the service user occupying Room 9 moves out of this room this can no longer be used as a bedroom, and the Commission must be informed. Date of last inspection 09 December 2004 Brief Description of the Service: The Croft is a detached property set within its own, well maintained grounds. The home is within easy reach of the main street and facilities of Whalley, including shops, churches, post office, health centre and public houses. The Croft is registered to offer accommodation and personal care to 26 older people, aged 65 years and over. Accommodation is provided in 24 single bedrooms, some with en suite facilities, and one double room with en suite facility. There is a lift to provide access to the upper floor, and there are various adaptations to assist service users with self- help and mobility. There are lounge areas on both floors, and a dining room on the ground floor. Smoking is permitted in one lounge area. The garden has seating areas for residents and there is car parking space available. At the time of the inspection there were 24 residents placed at the home. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It took place over one day. There were 24 residents accommodated at this time. Over the course of the inspection approximately 12 residents were spoken to. Three staff members were also spoken to. A tour of the home took place, including all bedrooms. Documents were read and care observed. Since the last inspection the previous manager had left The Croft. A new manager was due to begin the week following the inspection. This inspection was conducted with the registered person Mr Lucas. What the service does well: What has improved since the last inspection? What they could do better: The recording of residents’ needs and how these will be met could be improved in the care plan format. Risk assessment’s must also be completed in order to establish and ensure residents continued safety. The practices for administering residents’ medication needed further improvement. Daily activities on offer to residents should be planned and recorded. Further revision of The Croft’s complaints and protection from abuse policies and procedures would be of benefit in ensuring the safety of the residents. Procedures for the recruitment of staff did not include all the checks required to safeguard the residents. It was difficult to evidence that residents were consulted about the running of their home. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 EVIDENCE: Neither of these standards were looked at during this inspection. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 All resident’s care and health needs, and how these must be met were not appropriately recorded. Regular reviews of care plans ensured that any changes were documented. Not all risks were assessed to ensure that all residents were safe from harm. Appropriate, safe administration and disposal of medication must be ensured. EVIDENCE: The inspector looked at two residents care plans. Information on each resident was recorded on a Cardex System, a medical model. On this, was information identifying each resident’s health and care needs, but not what support was needed in order to meet those needs. One resident said, “ They (the staff) can’t do enough for you”. From observations, speaking to residents and visitors the inspector felt that staff knew resident’s needs. The two care plans examined had both been reviewed within the past two months. One resident did not have a dependency profile. One resident had been visited by the GP, but no record had been made of this visit. One resident had no mention of his lower false teeth not fitting, or what was being done to remedy this, under the oral health records. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 10 Risk assessment for moving and handling only were seen. It was identified that other risk assessments were needed in order establish and ensure residents continued safety. The inspector advised that all residents are entitled to an annual medication review. Medication is dispensed in the Venalink system. The inspector advised that the registered person or manager must have sight of the prescriptions before they go to the pharmacist, instead of the present system where the pharmacy collects the prescriptions from the GP’s surgery. The inspector also advised that medication stored in the fridge must be dated at the time of opening. The fridge temperature book had not been completed since March 2005. A number of old medications should be returned to the pharmacy. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The inspector was satisfied the care staff knew individuals preferences and choices, however activities of interest and giving stimulation should be arranged for residents and their outcome recorded. Meals were varied and enjoyed by the residents. Health and safety issues must be addressed regarding the high temperature of one fridge. EVIDENCE: Residents’ previous hobbies and interests were recorded during the assessment process but this information was not used in the development of care plans. Service users said that staff organised some activities but there was no regular programme. There was no record of any activities that had taken place. A requirement was made in this respect. The inspector ate lunch with the residents and complimentary comments were made by a number of residents about the quality and quantity of food served at The Croft. A record of meals served was now being made. There was a 12 week menu in place, and alternative options were available. The inspector noted that records were made of fridge and freezer, and that one fridge was regularly 9/10 degrees centigrade. This must be closely monitored, as fridges must be kept below 8 degrees centigrade. A requirement was made in this respect. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The protection of residents must be paramount and this demonstrated accordingly in robust policies and procedures. Further revision of The Croft’s complaints and protection from abuse policies and procedures would be of benefit in ensuring the safety of the residents. EVIDENCE: Staff spoken to by the inspector could describe the procedures to follow should a complaint be made to them. They would record the issue raised on the residents’ daily records. There was a copy of the homes procedure on display in a communal area of the home. There was a complaints record book, however, no entry had been made since 2003. The inspector advised that the complaints policy and procedures must be reviewed, for example, more detail regarding strategies for an informal and formal procedure. Staff could also describe to the inspector the procedures they would take if they observed any incident of abuse. They were aware they could raise their concerns with the Commission. The inspector noted the homes policy entitled “Protection of Residents from Abuse” – this policy was not dated nor was it specific to The Croft. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The home was clean, tidy warm and free from offensive odours. Laundry facilities were not fully adequate to the needs of the residents and staff at the time of the inspection. EVIDENCE: There were no independent sluice or hand washing facilities such as a suitable type of hand wash or paper towels in the laundry. There were two industrial washing machines, which had a sluicing cycle. There were also 2 industrial standard dryers. In addition there was also one domestic washing machine. Staff spoken to felt they would benefit from the use of an independent sluice. The laundry was sited well away from food preparation areas although one route to the laundry might be through the kitchen. The registered provider advised that staff were expected to always use the one route away from the kitchen. There were policies and procedures available for staff to follow regarding the control of infection. Staff spoken to said protective clothing such as gloves or aprons were available. The inspector found the home to be clean and odour free. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 14 The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 The procedures for the recruitment of staff did not include all the checks required to safeguard the residents. The inspector was unable to ascertain if the outstanding requirement (regarding staff training) from the previous inspection had been met. EVIDENCE: Two staff files were examined one was found to be in accordance with Schedule 2 of the Care Home Regulations, however the other was not. The registered person was not aware of the POVA (Protection of Vulnerable Adults) procedures introduced in July of 2004. The registered person was unable to locate the training matrix to demonstrate any staff training recently undertaken. Nor was there evidence that the cook most recently employed had completed the Food Hygiene Certificate. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 & 38 It was difficult to evidence that residents were consulted about the running of their home. Some records were seen regarding the health and safety of the home. The new manager must register with the Commission. EVIDENCE: Since the last inspection the registered manager had left the home. A new manager was due to start work the week following the inspection. The registered person advised the inspector that a business plan was not yet in place. This issue was discussed. There were no records of residents meetings available. The inspector and registered person discussed how this could be done on an informal basis, but that the outcomes must be recorded. The inspector was advised that a visitors’ questionnaire had been developed, and that this was left out at the homes entrance, however it was rarely if ever completed. The inspector advised that this should be posted out to residents The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 17 and their regular visitors (family, friends and visiting professionals) twice a year, and the response collated and published. Requirements were made in regards to these issues. The inspector saw certificates regarding the servicing and maintenance of the central heating boiler, the passenger lift, fire extinguishers and electrical installations. The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 2 x x x x x The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 19 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 OP7 Regulation 15(1) Requirement The registered person must ensure that service users needs in respect of their health and welfare are to be met. The registered person must ensure that policies and procedures for all aspects of medicines management be produced in line with the Royal Pharmaceutical Society of Great Britain guidelines. The registered person must, after consultation with service users, provide a programme of regular activities. Regular monitoring of fridges and freezers must take place and and remedial action taken as required. The complaints policy and procedure must be in accordance with these regulations. The protection of residents from abuse must be paramount and this demonstrated accordingly in robust policies and procedures. The registered person must provide sluicing facilities at the home. Records detailed in this Schedule must be kept regarding each Timescale for action 2nd September 2005 2nd September 2005 2. OP9 13(2) 3. OP12 16(2)(n) 1st July 2005 20th May 2005 2nd September 2005 2nd September 2005 30th December 2005 20th May 2005 Page 20 4. OP15 & OP9 OP16 OP18 13(3c) 5. 6. 22 & Schedule 4 (11) 13(6) 7. 8. The Croft OP26 OP29 23(2)(k) Schedule 2 F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 staff employed at the home. 9. OP30 18(1c) Staff must receive training appropriate to the work they are to perform. This would include update training in safe working practice topics. The registered person must ensure quality assurance documentation meets all the elements contained within this standard. The registered person must produce a business and financial plan. 2nd September 2005 2nd September 2005 2nd September 2005 10. OP33 24 11. OP34 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Croft F57 F57 S9432 The Croft V221297 May 20th 2005 Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection 1st floor, Unit 4 Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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. 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