CARE HOME ADULTS 18-65
The Croft Village Hawcoat Lane Barrow-in-furness Cumbria LA14 4HE Lead Inspector
Ma Unannounced Inspection 5th January 2007 09:30 The Croft Village DS0000022631.V319413.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 Village DS0000022631.V319413.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 Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Croft Village Address Hawcoat Lane Barrow-in-furness Cumbria LA14 4HE 01229 840064 01229 431645 Colette@croftcaretrust.co.uk 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) The Croft Care Trust Post Vacant Care Home 23 Category(ies) of Learning disability (23), Learning disability over registration, with number 65 years of age (5), Physical disability (6) of places The Croft Village DS0000022631.V319413.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 LD (Learning disability) up to 6 service users in the category PD (Physical disabilities) up to 5 service users in the category LD(E) (Learning disabilities over 65 years of age) Date of last inspection 6th March 2006 Brief Description of the Service: The Croft Village is a purpose built care home that provides accommodation and care for up to twenty-three adults with learning and/or physical disabilities. The home is owned and run by the Croft Care Trust. The village has two bungalows named ‘Hope’ and ‘Peace’ and two houses named ‘Trust’ and ‘Love’. Nineteen of the 23 bedrooms are on the ground floor with four first floor bedrooms that are reached by stairs for residents assessed as suitable. The village has its own clubhouse, workshops and craft rooms, a chapel, a post box and telephone box and a tuck shop that sells every day items. The residents also have the use of the hydrotherapy pool and light stimulation room in the Croft Nursing Home, which is on the same site. The home is close to local bus routes, public houses, shops and amenities. The main kitchens are within the Croft Nursing Home, although the bungalows and houses all have their own kitchen areas for residents to use. The gardens surrounding the bungalows/ houses are well maintained and landscaped with decorative features, including water features and bridges. All areas of the village are accessible for wheelchair users. Fees payable at the home range from £350.00 to £650.00 a week as at 5th January 2007. There are additional charges for newspapers and magazines, personal toiletries, sweets, individual hobbies and activities and holidays. The home makes information about its services available through its service user guide and statement of purpose. These and previous inspection reports are easily available in the home. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on 5th January 2007. The inspector looked around the home and spoke with the Executive officer for the organisation, the Responsible Individual, the manager, residents and with staff members. Staff recruitment records, training records, medication handling records and care plans were examined and a selection of other records required by regulation. Time was spent observing staff and residents activities and interactions during the day. Information about the home and its services, asked for by the Commission for Social Care Inspection (CSCI), was provided before the inspection took place. Before the visit information was also gathered on the service from records of previous visits, notifications and other regulatory activity. Questionnaires from residents and relatives about the service, provided by CSCI, were returned before the inspection took place and also provided information about their experiences of the home What the service does well:
Residents spoken with like living at the village and like the staff who help and support them. There is a close supportive relationship evident between residents and staff that works to promote choice. The care staff and manager put a lot of time; effort and planning into supporting residents to chose and take part in a variety of educational, social and leisure activities inside and outside the home. One resident commented “ I always have a great time and fun with other people”. The home provides and facilitates a wide range of recreational activities with a resident focused and varied programme with in house and external activities taking place all week. Residents are also being well supported to be involved in clubs and activities outside the home and to meet and mix with people outside the home through training programmes or leisure. The service supports and encourages staff to undertake training and gain relevant qualifications and to come forward with ideas for improvement with an organisational culture that values staff development. Staff morale is good and there is very little staff turnover giving consistency in resident’s everyday lives. The home maintains a consistently high standard of care planning that focuses on the individual and their needs and aspirations and reflects a resident centred approach to life in the village. The home involves residents very much in planning their care and daily lives with person centred care planning developed with the individual resident. This allows individual aspirations and goals to run through the care and reflect what they want in their lives.
The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 6 The home provides a homely communal atmosphere for residents who take pride in their home and gardens. The home makes changes to the individual and shared accommodation only following resident involvement and to reflect what they want from these spaces. There is a high standard of catering with varied menus and a broad range of choice available to residents. Good kitchen facilities allow residents to do some of their own cooking if they want to. The home has an open and transparent approach to management and resident and staff involvement, consequently there is a shared vision of how the home can develop its services to reflect what the residents living there want from their home and care. The home provides a safe, welcoming and homely atmosphere. Attention is paid to detail and in helping residents to choose how they personalise and decorate their own rooms supported by their key workers. Procedures are in place, reviewed and followed to ensure that residents are protected through the recruitment and selection of staff and their induction to the home as well as by staff making referrals to other professionals for information and support when needs change or when issues are identified. What has improved since the last inspection?
The senior management team is now more open and innovative and very clear about their roles and responsibilities and are working closely with the residents and care staff to develop services for the residents. The new management team has made some important changes to what were already effective systems and practices but has made them more transparent and open improving resident involvement. The homes quality assurance practices, including audits and reviews of practices are now being given a higher priority indicating that the desire for evidenced improvement and development of services for residents. The care plans in use are being reviewed and improved on an ongoing basis using a person centred approach to planning care and giving care that the home is continuing to develop with the residents to improve their quality of life and reflect their goals. Improvements to the overall environment for residents are evident in the use of communal space, including opening up the lounge and conservatory areas in ‘Trust’ house making it more open plan as residents wanted and easier for wheelchair users. It has been redecorated in a light colour scheme that residents chose and makes it a much brighter space. Alongside this the patio area outside ‘Trust’ and ‘Love’ houses have been significantly extended so more residents can use them, especially those using wheelchairs. Residents like this improvement as many like to take their meals outside when the weather allows. Resident’s bedrooms are being improved with redecoration and new carpets using colours and materials the residents have chosen as part of its ongoing
The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 7 maintenance. One resident has had an overhead hoist installed to better meet their mobility needs and they said this has created more space for them. New bathing equipment in addition to existing equipment means that whatever a residents disability there is safe and reliable equipment for them. Improvements have been made to call bells in the workshop areas and the workshops have been opened up and made larger. Improvements to doors have been made to improve resident’s privacy in their home, with frosted glass placed in the emergency/ fire exits so passers by cannot see in. Additionally new front doors have been fitted to the houses reflecting the kind of front doors that resident’s want on their own homes. Staff levels have increased with additional domestic staff and also care staff on duty and more workshop staff planned for. Additional care staff at weekends is to give residents greater choice in doing activities and going out if they want to. Staff morale is clearly improved with staff saying how well supported and involved they feel in the development and life of the home. This home has consistently worked hard at achieving the National Minimum Standards and providing good, safe care. Some of the improvements noted during the visit are the kind that are not easily measured such as the happy atmosphere and a raised awareness of equality and diversity and of the individual resident’s choice and aspirations. The care and management team have a shared vision for the home that is all about the resident and their choices and aspirations that has not always been so evident previously. Currently the home is improving on almost all levels, on an already good track record, to provide in a very real sense a home that reflects its occupant’s choices and needs. What they could do better:
The home has obviously been reviewing and evaluating its practices and the kind of environment resident’s want through better consultation, audits and monitoring and are presenting for a clear development plan for the home. The service has recognised, using its own internal systems, what residents want to change or improve to make a better home for themselves and is working towards maintaining very high standards. As long as they continue to work along these lines they should continue to improve the service as a matter of course. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 8 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 Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 9 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 Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 10 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): NMS 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from having their individual needs and aspirations thoroughly assessed before admission and from the home making sure they can be met. EVIDENCE: The home has a Statement of Purpose that gives up to date information about the home. Some of the information is in pictorial formats for residents who prefer this. Previous inspection reports are available in the home. Residents are admitted to the home only after a detailed assessment of their individual needs, their preferences and baseline daily living information has been done. This assessment is done using a systematic assessment tool and advice and support from other agencies and specialist services involved in the individuals care forms part of the process. The home obtains copies of the care management plans for the residents who are admitted under such arrangements. Information and advice is taken from other agencies involved in the resident’s care before admission, such as specialist nursing services, physiotherapy, wheelchair services and speech therapy. Families and other supporters are also involved in consultations on meeting individual needs. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 11 Staff have a range of skills, training and experience relevant to the needs of residents to provide care and support. Staff communicate effectively with residents and are aware of the particular communication methods and styles preferred by different residents. As part of quality assurance new residents are asked to complete a questionnaire on the admission process to maintain standards and make changes to the process if needed. Prospective residents are encouraged to visit the home before they decide to come and live there. One newer resident was able to make visits and choose the decoration, carpet and colour scheme for their bedroom before they came in so it was ready for their arrival. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 12 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): NMS 6, 7, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A comprehensive care planning and assessment system is in place, to provide information for staff on resident’s changing health, personal and social care needs and their individual aspirations. EVIDENCE: The individual resident care plans are clear, up to date and are being regularly reviewed and updated as resident’s needs and goals change. Clinical risk assessments and personal risk assessments are in place. Assessments outline the approach to risk management and any restrictive effect it may have on the resident. Resident’s and families are involved in developing the individual care plans, which are viewed as the resident’s own property. Information is also gathered for the care plan by the key worker, as well as with agencies advising on particular behaviours and/or conditions. This plan includes what residents want from personal care and how they like their days to go. Plans seen show the
The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 13 residents view of themselves, their stories and what they want for themselves, given the limitations imposed by individual conditions. Residents are currently working on further developing their own personal plans to go along side and inform existing care plans. These are their own personal documents reflecting their goals, aspirations and what has importance for them in daily life and relationships. A great deal of effort and thought is being put into this by residents with staff support and residents display a real sense of ownership of their work. There is evidence in the care plans and from the homes procedures that residents are assessed for potential and already identified risks that might affect their choices and personal such as community access and where behaviour has been unpredictable. Risk is being managed so that residents can live their own lives with suitable assistance such as independent travel and using public facilities and services in the community. All residents also hold their own individual medical records. These are their own property and residents take these with them to record their health care needs and views and for professionals to use and write in, with the resident’s permission. This is in pictorial formats and reflects resident’s health history and needs from their perspective. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 14 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): NMS 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are being supported to make decisions and choices in their lives and have opportunities for leisure activities, personal development and social inclusion that are culturally appropriate to them. EVIDENCE: Residents have their own personal activities schedules and those who want to can use local day services, social clubs, the library and the local adult education college. This enables them to mix with the other people, gain life skills, qualifications and participate in the activities on offer there. The home has its own chapel for prayer or quiet reflection and some residents chose to attend the nearby church. The home promotes independence as seen with one resident who is taking up some volunteer work and getting valuable employment experience as well and also in being supported to travel independently. Another resident enjoys going out to different organisations
The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 15 and groups in the local community to give talks about life at the Croft Village and the people living there. Within the home staff are heavily involved in supporting residents in social and leisure activities and personal interests so that they can make the most of the community. This includes shopping trips, using local public houses for an evening out and local clubs. The home is reviewing its activities programme as it is looking to make more use of local community leisure facilities, such as the local leisure centre and gym. This review is part of extending person centred planning so that residents can look at what is important for them and what opportunities they want. This can feed back into the new programme so they decide for themselves the activities and facilities they want. Additional support staff have been recruited to free more time to support residents in this. The home organises frequent group trips out to destinations chosen by residents and holidays. Residents are in the process of selecting their next holiday destination and this is to be discussed at the residents meting. Residents say that they enjoy their holidays and are very involved in planning them. Minutes of the residents meeting show that residents are asked what trips and outings they wanted. Menus seen showed a choice and range of nutritious foods and special and therapeutic diets. One resident is attending a cookery class and preparing their own meal whilst there. Residents, where possible, help prepare some meals such as breakfast. The main meals for residents are prepared in the main kitchen in the nearby nursing home and transported the short distance in heated containers. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 16 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): NMS 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Systems are in place to monitor and consistently meet resident’s changing personal, physical and emotional healthcare needs and preferences with specialist advice and clear instructions for staff. EVIDENCE: Individual care plans outline residents own choices on personal support, any individual limitations and risks, preferences for daily routines, clinical care assessments and moving and handling needs, along with assessments and instructions for staff to follow. It also indicates what they expect from their personal carers. All residents have a key worker they know well and who have a good understanding of them and their individual needs. These key workers are supporting residents in developing their individual personal plans. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 17 There are a variety of aids and equipment in use to promote resident’s independence and safe movement around the home and these are supported by relevant risk assessments. These assessments show a move towards a person centred approach with equipment and aids being provided and improved for each resident as needs change such as overhead hoists in one resident’s bedroom. The resident said what a great improvement the hoist was for them as it made moving about easier for them and meant they had more space. Medication systems and storage are well organised and records are clear and up to date with systems in place for recording all medications received and the safe disposal of medicine waste. Medication policies, procedures and practices are subject to audit as part of quality monitoring and new procedures have been introduced where needed. Information on different medication and conditions is available to staff and includes notes on the medication and ‘as required’ medication, indications for its use, administration methods and dosages. Some residents are being supported to control some of their own medicines, following a thorough risk assessment. The risk assessment is reviewed at the monthly audit to ensure it is still appropriate. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 18 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): NMS 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system available in different formats to suit different resident’s needs. Adult protection procedures and staff training help safeguard residents from abuse and harm. EVIDENCE: The home has a clear complaint procedure, displayed within the home and also provided in pictorial formats for residents and visitors. There are systems for recording and investigating any complaints and recording outcomes and actions. Information on advocacy is available for residents in the home and can be obtained for anyone who asked. The home has books for residents in pictorial formats for visual representation that many residents find easier to follow on matters like “speaking out” and “saying what they want”. This is useful for some residents to help express their thoughts on these subjects. The home has its own adult protection procedures in line with current multi agency guidance and policies for the protection of vulnerable adults and on whistle blowing. Training records indicate that staff have been given training on adult protection and on managing challenging behaviours. Questionnaire responses indicate that residents and relatives feel listened to and have faith in the staff to deal quickly with any problems or complaints. Residents spoken with felt they could rely on their carers to keep them safe. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 19 There are procedures in place to safeguard resident’s financial interests. All financial transactions are recorded and residents have their own individual accounts and records of spending money. These involve families and representatives in supporting residents in dealing with their finances. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 20 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): NMS 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a well furnished, clean, safe and homely place to live in with the equipment resident’s need to promote their mobility and physical independence. EVIDENCE: The home is well maintained, well decorated, is clean and tidy and has a range of adaptations to suit residents assessed needs. The home has its own gardener and maintenance person to keep the buildings and grounds in very good order. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 21 Many residents have their own individually adapted equipment in their bedrooms and the home has recently installed an overhead hoist to better meet one resident’s individual mobility needs. Several bedrooms have been redecorated and arranged according to resident’s wishes and decoration choices and to accommodate the personal things that are important to them. There have been significant improvements around the use of communal areas and in making sure that any changes to the environment are what residents have asked for and decided upon. The lounge and conservatory in ‘Trust’ has been opened up to make it open plan. Residents say they prefer this as it makes the rooms lighter and easier for those in wheelchairs to move around independently. Resident’s worked together to decide on the flooring, wallpaper and paint colours used to redecorate it. Also in consultation with residents the patio area outside the conservatory has been made larger so residents can eat outside if they want and wheelchair users can have easy access to this new area. A lot of consultation goes on as the norm in the home and when changes have been made it is because it is to suit resident’s lifestyles and to promote their independence. Specialist equipment, for moving and handling, bathing and promoting physical independence are provided to meet the individually assessed needs of the residents and to promote independence and privacy generally. This includes fitting new front doors to the houses and bungalows so that residents can come and go as they please. Fire doors have frosted glass now to improve privacy in the individual buildings. The home has its own small well-equipped laundry away from communal areas with domestic washing- machines that residents can use. The addition of a dedicated medication room has improved the homes medication storage and preparation area. There are policies and procedures in place for infection control including MRSA and procedures are in place for the safe handling and disposal of any clinical waste. The home does not have a separate sluice facility. However the home aims and plans resident’s care with them to promote an independent way of life and the facility is not routinely needed at present. At the time of this visit the desired outcome for residents is being achieved without the need for a sluice facility. Washing machines have a sluice facility for linen. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 22 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): NMS 31, 32, 33, 34, 35 and 36 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There is a well supported and appropriately trained staff team that works well with residents to promote independence, choice and quality of life. EVIDENCE: The Croft Village has a stable staff group, with very little staff turnover. Staff spoken with enjoy their work and are highly motivated to train and develop their skills and the service. One staff member said,” I love my job” another that “ I really enjoy my work” and their enthusiasm and commitment was evident from their comments and observed interaction with residents. Staff responses to questions indicate they know the residents well, their personal interests and backgrounds. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 23 A high level of personal commitment by staff to improving the quality of life for residents and offering greater choice is evident. Staff know the residents well, their personal interests and backgrounds and approaches are friendly and supportive. Staff spend a lot of time with residents supporting them and looking for ways to help them achieve their potential. The home has robust recruitment records and procedures that are being followed to make sure that staff have the necessary Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks before starting work. The home has a clear staff handbook and staff are aware of their roles and responsibilities. Records and staff comments show that regular formal supervision is given to them and support in their work and supervision given on a daily basis. There is a well organised and financed programme of training and individual staff development covering a range of topics relevant to the resident’s needs. There is an established induction and training programmes covering mandatory training and giving access to a variety of planned training opportunities. Roles and responsibilities for staff and management are clear and there is a clear and open management approach for staff and residents. There is a discernable sense of staff and resident involvement in the daily life of the home where everyone works together and is not afraid to put their ideas forward. This can be seen in items raised at resident and staff meetings but also in the changes that have already taken place. The home has a very high percentage of staff with NVQ qualifications at level 2 and above. Staff rotas show sufficient numbers of staff are on duty to meet resident’s needs during the day and night. Additional staff have been recruited for domestic work and at weekends to free carers to be able to offer residents more choice in what they want to do with their support. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 24 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): NMS 37, 38, 39, 40, 41, 42, and 43 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well run with effective management and direction for staff to make sure that residents receive a consistently high and safe standard of care that promotes resident’s personal and financial and interests. EVIDENCE: There is an open and responsive management structure in place. The management team are clear about their roles and responsibilities with a definite vision for the development of the home and services to reflect what residents ask for. There is a clear emphasis on residents influencing the running of their home on a daily basis from putting forward their own ideas and opinions to seeing them to a practical conclusion, such as changes to the environment, staffing, their holidays and leisure opportunities
The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 25 The acting manager is in the final stages of registering with the Commission for Social Care Inspection (CSCI) as registered manager. They are experienced in working in this care setting and supervising staff and have NVQ level 4 in care. They are in the process of doing the Registered Managers Award (RMA) and is being well supported by senior management as they gain management experience. The leadership and management approach in the home is open and positive which encourages comment and new ideas. The home has regular meetings with staff and residents and regular newsletters that keep everyone informed. The home seeks opinions from the families and friends of residents and from health care professionals, trainers and other agencies that come in contact with the home. This broad sweep helps to get different opinions and see what needs improving from different perspectives. Audits are being done on care planning and medication systems, evident in problems being picked up and addressed quickly and in identifying areas to further improve. Policies and procedures are being reviewed and updated to reflect changes in good practice and legislation. Management and financial systems in the home are subject to review and there is clear accounting and audit system. The standard of record keeping required by regulation is of a high standard and residents have opportunities to have control over their healthcare and care planning records with support. Records are kept of maintenance and the home has fire training and servicing and testing practices to promote resident health and safety. There is evidence that appropriate testing and servicing of equipment is being carried out and that the home does Legionella and water temperature testing. Insurance cover is in place for the home and is displayed. The Croft Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 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 4 25 3 26 3 27 3 28 3 29 4 30 3 STAFFING Standard No Score 31 3 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 4 3 3 3 3 3
Version 5.2 Page 27 The Croft Village DS0000022631.V319413.R01.S.doc 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. Standard Regulation Requirement Timescale for action 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 Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Village DS0000022631.V319413.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
