Inspection on 28/06/05 for Clayton Brook House

This inspection was carried out on 28th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clayton Brook House 04/11/08

Clayton Brook House 27/09/06

Clayton Brook House 19/01/06

Clayton Brook House 18/11/04

Clayton Brook House 18/05/04

Clayton Brook House 24/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Clayton Brook House 90 Atlas Street Clayton-Le-Moors Accrington, Lancashire BB5 5LT Lead Inspector Lynn Mitton Announced 28 June 2005 13:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clayton Brook House Address 90 Atlas Street Clayton-Le-Moors Accrington Lancashire BB5 5LT 01254 875340 01254 888535 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) The National Autistic Society Mr David William Woof Care Home only Personal Care (PC) 6 6 Category(ies) of Learning Disability (LD) registration, with number of places Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 November 2004 Brief Description of the Service: Clayton Brook House is registered to accommodate 6 persons, and is part of the Hyndburn National Autistic Society Scheme, which has two other residential care homes and a domiciliary support agency, and is a charitable organisation specialising in caring for those diagnosed with Autistic Specific Disorders. Clayton Brook House is a detached purpose built establishment with six single en-suite bedrooms. Service users accommodation is based on the ground floor. The home had been decorated and furnished to meet the needs of service users, bearing in mind the specific needs of those with Autistic Spectrum Disorder. A secure and private garden is also available. Facilities are available for guests to stay overnight. Clayton Brook House is located in a popular residential area, within walking distance of local shops and bus routes. Parking is available at the front of the home. Clayton Brook House is registered with the Commission for Social Care Inspection to provide personal and social care for up to 6 people aged over 18. At the time of the inspection there were 6 people accommodated. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and lasted approximately 7 hours. There were 6 service users accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection three of the staff on duty, plus the registered manager were spoken to, interaction between the service users and staff members were observed. Policies and practices were also read. Some service users relatives had completed the Commission’s comment card, and one service user had completed the service users survey. These indicated that they were very pleased with the level of service received at Clayton Brook House. What the service does well: What has improved since the last inspection? The statement of purpose and service user guide had been improved to better inform potential service users. 58 of staff had completed NVQ 2 or NVQ 3 training to help them meet the needs of service users. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 The written information provided a clear picture of the homes’ facilities and services. EVIDENCE: An updated statement of purpose and service user guide had been produced. These documents now contained the required information needed for service users to understand how the home was run and what facilities were offered, and the service user guide had been completed pictorially. There had been no new admissions to the home since July 2002; therefore no assessment of needs had been required. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 The care needs of service users were identified and documented. Service users individual needs were know by staff. Service users were enabled to make day-to-day decisions about their lives. Regular reviews of care plans and risk assessments ensured that any changes were regularly documented and that any action needed was taken. The risk assessment and management framework supported service users to take responsible risks. EVIDENCE: Service users had a comprehensive care plan in place that included a plan of action of how to address service users specific needs and included information such as a personal profile, behaviour support plan and positive intervention strategies. One care plan was examined in detail during the inspection. It gave a good account of that persons specific needs and how they should be met by the care staff team. Daily records seen gave a good account of events and activities undertaken during each day. Whenever possible, service users were given information and options to help them make positive decisions about their own lives. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 10 Risk assessments were an integral element of the service users care plan and a number had been completed. The care plan and risk assessments had been recently reviewed. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15, 16 & 17 The home was run to make sure the service users enjoyed their life and had opportunities to fulfil their potential. Service users had regular access to their local community, and had opportunities to maintain family links. Service users were respected and felt valued as individuals. Individual dietary needs were catered for with care and sensitivity. EVIDENCE: Each service user had a daily activity programme. One service user worked in a supported placement 1 day per week at a retail store. Other activities undertaken included using local community and sport facilities and attending the Atlas Day Centre. The activity programme case tracked however was out of date. The inspector observed personal interests (often Autism specific) being supported in a structured way in order to maintain service users well being. All the service users had either been on or had a weeks’ holiday planned. Some service users had two or three short breaks or day trips according to each persons needs. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 12 Service users were able to keep in regular touch with their families and friends, by ‘phone and mail, though most of the service users lived a long way away from their family. There was a bedroom available to accommodate visitors. One family member commented to the Commission “ I am always given a hearty welcome, and kept well informed of any changes in the care of my son”. The 6 weekly menu was seen and during the inspection it was observed that alternatives to the menu were offered to accommodate all service users preferences. A record of food eaten was also kept. Staff were observed working closely and flexibly with individuals, knowing their likes and dislikes, monitoring food intake, staggering mealtimes and accommodating “fads”. Service users were observed to be treat with dignity and respect. One family member told the Commission “We are delighted with the care our son receives at Clayton Brook House. We feel he is liked and respected by all the staff”. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 21 Service users health needs were known and being met. Minor amendments would ensure good practice was in place with regards to the administration, safekeeping, storage and disposal of service users medication. EVIDENCE: The service user case tracked had a health check document dated June 2005. There was detailed information regarding meeting all the service users health needs. This included regular weight checks and records of all optical, dental GP, chiropody and psychiatry appointments. Policies and practices for managing and administering medication were in place. Medication was administered using the Boots Monitored Dosage System. All service users had their medication administered by care staff. Information regarding consent to medication being administered by staff was given to the registered manager. Policies and practices for the safe administration of medication were in place. All staff had completed basic Boots medication system training, however, accredited training for staff regarding the safe administration of medication had not yet taken place. Administration records were completed correctly. Good practice such as patient information leaflets and an initial register were in place. Medication not suitable for the MDS was stored in plastic boxes named Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 14 for each service user. There was overstocking of some medication and some medication was dated 2003. The registered manager and inspector discussed these issues. The inspector advised that it was important that care staff have sight of prescriptions before they go to the pharmacist for dispensation. There were records in place recording service users family’s wishes regarding the death of their next of kin. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 There were clear complaints and protection policies and practices in place. Staff spoken to had a good understanding of adult protection issues and how to deal with complaints made by service users. EVIDENCE: There had been no complaints since the last inspection. The complaints procedure was now available in a pictorial format, which was more appropriate for some service users living at Clayton Brook House. Staff spoken to were able to describe the complaints procedure and how they would deal with someone making a complaint. Staff spoken to were also able to give definitions of different types of abuse and how they would act if they witnessed abuse of any kind. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 & 30 The standard of cleanliness and hygiene in the home was satisfactory. Staff to fill the ancillary vacancy should be pursued as soon as possible. EVIDENCE: Furnishing omissions in service users bedrooms were recorded on the service users care plan case tracked. The Environmental Officer had visited Clayton Brook House in October 2004 and declared the premises satisfactory. The inspector noted that fridge and freezer temperatures were recorded daily and were in order. There were no ancillary staff employed at the time of the inspection. The 20hour per week vacancy was being pursued with an independent cleaning agency. Care staff were undertaking these tasks in the meantime. The home was clean and odour free. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 35 & 36 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. Staff should continue to complete their NVQ training to enable them to better meet the needs of service users. EVIDENCE: The inspector noted that 8 out of 15 care staff members had obtained their NVQ level 2 and 3. The inspector case tracked 2 employees who had most of the information required available to the inspector. Criminal Record Bureau records were not available to the inspector. One staff member did not have a photograph on their staff file. There was evidence of staff training, and that management, support and development meetings took place with managers and staff members. There had been four team staff meetings held during 2005 and the minutes of these meetings were seen. One family member wrote to the commission saying “without exception each member of staff is warm, courteous and friendly and all show a deeply caring nature and a sensitive approach”. The inspector observed service users being supported by competent staff. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 & 43 The registered manager should complete his NVQ 4 training at the earliest opportunity. Service users families were kept in touch with any changes in their son or daughters needs. This was of great importance to them. The home was run to ensure the safety and welfare of residents and staff were safeguarded. General good practice was in place with regard to the safety and welfare of the staff and residents. EVIDENCE: The registered manager had completed 6 elements of the NVQ 4 in Management training. Surveys had not been conducted with service users due to their ability, however comments received by the Commission, and seen on the day of the inspection indicated that service users families felt very involved and were kept fully informed about their son/daughter. A letter of appreciation had been received regarding one service user who had been very ill recently, and another service users parent wrote “the staff are always keen to involve me closely in their care of my son – should any change be undertaken I am Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 19 informed immediately”. The inspector and registered manager discussed the implementation of surveys of service users next of kin to see if the service can be improved. Regulation 26 reports on behalf of the registered person were being regularly completed. The inspector noted a number of up to date safety certificates issued with regard to the routine maintenance and safety of Clayton Brook House. Staff spoken to could describe what to do in the event of a fire. Potential trip hazards in the grounds of the home were pointed out to the registered manager. There was an up to date business and financial plan in place and a copy of this document was supplied to the Commission. Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 2 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clayton Brook House Score x 3 2 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 3 3 F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 21 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 YA20 Regulation 13(4c) Requirement Uneccessary risks to health and safety are identified and eliminated in that medication must not be overstocked and unused or out of date must be regularly returned to the pharmacist. A recent photograph must be kept in respect of each person working at the home. CRB records must be kept at the home and be available to the inspector. Timescale for action 28th June 2005 2. 3. YA34 YA34 Schedule 2 Schedule 2 28th June 2005 28th June 2005 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 YA12 YA37 YA39 Good Practice Recommendations Service users activity programme should be up to date. The registered manager should attain NVQ 4 in management and care (or equivalent) by 2005. The implementation of a survey or questionnaire, to regular visitors of the home to ascertain their views on the service received and how/if it can be improved Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, 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. Extracts may not be used or reproduced without the express permission of CSCI Clayton Brook House F57 F07 S9567 Clayton Brook House V225971 280605 Stage 4.doc Version 1.30 Page 23 - 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!