Inspection on 15/07/08 for Cleggsworth Care Home Ltd

This inspection was carried out on 15th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cleggsworth Care Home Ltd 15/06/09

Cleggsworth Care Home Ltd 12/07/07

Cleggsworth Care Home Ltd 28/11/06

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Cleggsworth Care Home Ltd 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA Lead Inspector Sue Jennings Unannounced Inspection 15 July 2008 11:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleggsworth Care Home Ltd Address 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA 01706 379788 01706 379788 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) Cleggsworth Care Home Ltd Mrs Audrey Bolton Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 38 service users to include: *up to 38 service users in the category of OP (old age not falling within any other category). 12th July 2007 Date of last inspection Brief Description of the Service: Cleggsworth House is registered to provide personal care and accommodation for 38 older people. It caters for both long term and respite stays. The home is located in Smithybridge village, which has a variety of shops and other amenities close by. It is near to public bus routes and the train station is in close proximity. The home consists of a two-storey building with purpose built extensions having more recently been added. With the exception of one double room, all rooms were single. En-suite facilities are provided in eight of the bedrooms. There is ramped access to the front entrance and a passenger lift is provided. Garden areas are provided to the rear of the building. The home’s Service User Guide advised residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. The fees were £352-82 to £459-69 per week. Additional charges were made for hairdressing, trips, newspapers, telephone, alcohol, clothing and personal toiletries. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is three stars. This means that people who use the service experience excellent quality outcomes. The service had completed an Annual Quality Assurance Assessment (AQAA) sometime before this inspection took place. The AQAA gave the service the opportunity to tell us what they do well, how they had improved in the last twelve months and their further plans for improvement in the next twelve months. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 5.5 hours on Tuesday 15th July 2008. During the course of the site visits time was spent talking to a visiting district nurse, the manager, the proprietor, 5 residents and 3 members of staff to find out their views of the home. In addition we received completed survey forms from residents and staff. The inspector spent time examining records and the residents and staff files. A tour of the building was also made. What the service does well: Comments from people who use the service included “they look after me really well” and “very pleasant”. One visitor to the home told us “They treat residents with real affection”. People living at the home told us they enjoy the food provided and that staff were friendly and polite. Staff records are well kept and include all the important checks to help protect people living at the home. A good programme of training is made available to care staff. People thinking about moving in were invited to visit and spend time with an allocated member of staff, the residents and to enjoy a meal. Staff reported that the management team were “very supportive and very helpful”. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is made available about the home and assessments are completed before people move in to make sure that their individual needs can be met. EVIDENCE: There was information provided to prospective residents that gave enough information for people to make an informed decision about moving in. A user guide is available which contains information about the service provided. The manager told us that this could be made available in large print if requested. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 9 The guide gives the current fees and any additional charges. People moving in have a trial period of six weeks to see if they like it and to make sure that the service can meet their needs. We saw that there is an admissions procedure and that pre-admission assessments are completed by an experienced member of staff to ensure all needs can be met. Assessments are completed prior to anybody moving in and this is done during the visit to the home or the manager will visit the propsective resident in hospital or in their own home, whichever is the most convenient. Once an individual comes to live there, a care plan is written based on these assessments. The manager or deputy manager visited the person in their own home or in hospital to carry out a pre-admission assessment. Where possible a care manager’s assessment was obtained. A care plan was written using the information gathered during these assessments. A sample of assessments of three people were examined and found to contain some good information. They told us that prospective residents are invited to visit and stay for lunch or a cup of tea or coffee with family members. Residents and relatives spoken to said that they were given an opportunity to visit the home before making a decision to move in. Residents told us “I came and saw the home first” and “My family came to look around” A relative or friend told us “This is a very good home”, “the best I could of found I chose this home on the advice of a friend” and “very pleasant”. Another relative or friend told us “ we are really happy” and “the care is excellent” another said “I chose here after looking at every home in the area with a vacancy, this was the very best it was homely and it felt nice”. This home did not provide intermediate care. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met by the home and medication practices safeguard residents. EVIDENCE: We saw the care plans of four residents. These contained enough information about how residents’ needs were to be met. There was evidence to show that care plans were being reviewed regularly. As stated in the last report care plans contain information about family history and residents’ hobbies or interests, which the home endeavours to use to identify suitable activities to meet the needs of individual residents. We saw records of professional visits such as chiropodist, opticians, doctors and district nurses had been recorded in the care plans. They told us that residents are able to choose their own doctor and have access to all NHS healthcare facilities in the local community. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 11 Risk assessments around areas such as falls, pressure areas and nutrition had been carried out but these were not really clear. It was recommended that they make some minor adjustments to the form so that it clearly identifies the risk to residents and also clearly identifies the action required to minimise those risks. The daily notes kept by staff did not reflect the good care practices observed on the day of the site visit. We saw that some of these were very repetitive with general statements such as ‘fine today” and “all care needs met’. Notes kept by staff should contain good information, which can then be used to evaluate and review the care being provided. It was recommended that daily notes reflect the care delivered to residents. Staff showed awareness of how important it is to identify changes in resident’s mood, behaviour and general wellbeing and fully understand how they should respond and take action. They told us they work closely with district nurses, tissue viability nurses and doctors for advice and support to help the resident, relatives and the staff. We observed staff delivering care that was person centred, flexible and consistent. We saw that staff treated residents with sensitivity maintaining dignity and showing respect. Residents’ meetings are held and views are sought about the day-to-day running of the home. Residents are consulted about activities both in the home and the local community. There are no strict routines and residents can make choices about how they spend their days. All residents were registered with a local GP and where possible residents had retained their own GP. Medication was dispensed in a blister pack monitored dosage system was well managed, stored correctly and records were maintained to a good standard. Staff had received training in the administration of medication this reduced the risk of medication errors. Medication stock was adequate and a record was being made of all medication received in to the home and disposed of. There was a photograph of residents in the Medication Administration Record sheets to enable staff to recognise residents and minimise the risk of administration errors. We saw a list of staff responsible for administering medication; this was so that only staff trained to administer medication do so. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 12 A number of residents’ eye drops had been labelled on the outside box but not on the inner bottle. To avoid contamination if the box is lost or destroyed a label should be put on the box as at least two residents use this eye drop. The manager stated that she would speak to the pharmacist about this. We observed the senior care making a number of phone calls to the pharmacist. She told us “I don’t recognise this cream as this residents,. I checked the care plan first to make sure the GP had not been out to prescribe it but they have not so I need to check it out with the pharmacist”. It was later confirmed that the cream had been mislabelled. This was observant and good practice. A relative or friend told us “I am really happy with the care here”. Another told us “they are never sharp with the residents they are always kind”. A relative told us “they keep me informed if mum is ill they ring me day or night” and “if mum has to go to the hospital they ring us and we meet her there”. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a range of recreational activities. A well-planned and varied diet is provided and resident’s choice is very well catered for. EVIDENCE: Throughout the site visit residents were occupying themselves by reading or watching TV. Staff were observed welcoming visitors into the home. There was an open visiting policy and residents were able to see visitors in one of the lounges or in the privacy of their own rooms if preferred. One resident told us their visitors were always made to feel welcome and can visit at any time. Other residents said that they were able to have friends and family visit when they liked. A relative or friend told us “I can visit in the lounge or in mum’s room”. Menus were based on a four-week rota and were reviewed regularly to take into account resident’s preferences. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 14 The cook told us that he knew the residents likes and dislikes and that staff went round each morning to ask residents what they wanted for lunch. A relative told us “mum likes the food she has never said any different”. Staff went round each morning to ask residents what they would prefer from the days menu. Residents were able to choose an alternative to the set menu if they did not like the menu choice for the day. We observed mealtimes to be a relaxed and pleasant experience for residents. Staff were observed sitting with residents assisting them and talking to them. One member of staff left the room only once to get a cushion to make a resident more comfortable. Residents told us, “the food is good” and “the meals are usually very good, very tasty”. Drinks are offered on a regular basis and any special dietary needs are highlighted in the resident’s care plan. They told us that ministers from local churches visited the home on a weekly basis. They told us that arrangements would be made to support residents from other religious backgrounds as and when required. They told us that they do not have an activity organiser at the moment and the rota identified a member of staff each day to do activities. Residents enjoyed a number of different in-house recreational activities that included outings to local areas of interest, clothes parties, day trips out, bingo, board and card games and professional entertainers visited the home. In the good weather residents are encouraged to maintain their interest in gardening. They told us that they try to encourage residents to be active and provided a range of opportunities for residents to maintain social/community contacts where possible. The home has visiting hairdressers that attend the home on a weekly basis. Residents told us “we have bingo and go out on trips”, ” there is something going on most days”. Residents told us that they had a choice of how to spend their day e.g. what time go to bed, meals, activities and what time get up We saw that staff encouraged resident’s choice and privacy and dignity was respected. We observed staff responding in a sensitive manner to residents care needs. We saw that that the manager and staff encouraged residents to maintain contact with family and friends. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a complaints procedure and policies and procedures were in place to make sure residents were protected from harm. EVIDENCE: There are suitable procedures in place for dealing with complaints. A copy of the complaint procedure is displayed in the hallway. The complaints policy and procedure is part of the guide for the people living there. We saw that a record of complaints was kept. No complaints had been recorded since the last inspection and the manager confirmed that no other complaints had been received. A number of very complimentary cards and letters had been received by the home thanking them for the care they have given. Discussion with residents demonstrated that they were clear about how and who to make a complaint to. One resident told us “I would speak to the manager or a member of staff”. A relative or friend told us “I have never had reason to complain but I am aware of the complaint procedure. “I would be comfortable talking to the manager she is caring and she always listens”. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 16 They told us they have policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the local procedures was also seen to be available. There have been no allegations of abuse. Staff have been given training in abuse awareness and we spoke to staff that were aware of the action to be taken in the event of an allegation of abuse. We saw they had a copy of Rochdale’s adult protection policy and procedure. It was recommended that the procedure used to refer any incidents of abuse is copied and displayed so that all staff are aware of the procedure. It was also suggested that they develop a flow chart of what action to take as an easy guide for staff. One member of staff told us “if I had witnessed someone abusing a resident I would first make sure the resident was safe and then tell the manager, if it was the manager I was reporting I would go to the owner or if it was the owner I would come to CSCI for advice”. This showed an awareness amongst staff that safeguarding residents is a priority. Independent advocates were sought where decisions affecting people’s rights and choices had to be taken and this was done with care and consideration. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are safe and the home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: There is a small quiet lounge on the first floor where residents can sit with their visitors in private in addition to the privacy of their bedroom. We saw that all communal areas are nicely decorated to provide a homely atmosphere. The dining room was at the front of the building and was bright and airy with a relaxed comfortable atmosphere. This was located next to the kitchen and staff served plated meals from the kitchens serving hatch. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 18 There was evidence that residents had brought some personal belongings with them. All rooms seen were found to be clean, tidy and nicely decorated and those residents spoken to said that they were very happy with their rooms. There was enough domestic staff to keep the home clean and we noted that there were no unpleasant odours during the tour of the home. A sample of bedrooms were seen and residents spoken to said “I like my room I spend a lot of time in here”, “the place is very clean”, “it is always very clean and tidy they work very hard” and “I am really happy here”. A relative or friend told us “it is always kept really clean there are no smells like there are in some places”. A relative told us “mums room is very nice it is always clean and tidy they do all they can to keep it like that”. Hoists were available for staff to transfer residents safely. Individual hoist slings are available for those residents needing to be hoisted. We saw evidence to show that staff had received manual handling training to enable them to use the equipment safely and safeguard residents. Ramped access was provided to the front door and level access throughout each of the two floors. There is a passenger lift to all floors to aid residents who are less mobile and have difficulty using stairs. General aids and adaptations are provided within the home such as grab rails. We saw they had an infection control policy was in place and training was provided in this area. We observed safe infection control practices being carried out by staff. Disposable gloves and colour-coded aprons were provided for staff use and liquid soap was available in toilets and bathrooms. Satisfactory practice was in place with regard to disposal of clinical waste. There is a patio area on the first floor balcony for residents to use and a well maintained garden to the rear of the home that residents are encouraged to use during the summer months. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff were sufficient to meet the needs of the residents accommodated and staff have access to a range of training. EVIDENCE: A sample of staff files was examined. These were well maintained and contained all the necessary checks including Criminal Records Bureau (CRB) checks and checks made against the Protection of Vulnerable Adults (POVA ) list. We saw copies of the staffing rotas. These showed that there were enough staff to meet residents’ needs. Five care assistants were on duty with the manager during the site visit. We saw that during the night two waking care assistants were on duty. The manager told us that following a number of residents falls early in the morning, day staff now start work at 7am and the night staff finish at 8am. This is to make sure there are sufficient staff to meet residents’ needs at this busy time. They told us this had managed to reduce the number of falls. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 20 Staff told us that that they had access to training. A training plan was seen that showed training in relation to manual handling, medication, fire safety, first Aid, and Protection of Vulnerable Adults had been provided. The manager told us that new senior posts had been developed and that this supported her management role. We observed one of the seniors to be professional in their contacts with other professionals such as GP’s and the pharmacist. The manager told us that regular staff supervision was provided where they are able to discuss residents’ needs. Future training needs can also be identified during these sessions. Staff told us they were aware of the various needs of the residents and showed that they understood their own role. They told us that all staff completed an induction period. They told us that staff meetings are held on a regular basis; these meetings are arranged so that both day and night staff can attend. They told us that all staff are encouraged to attend and discuss any issues they may have. There was evidence on staff files to show that staff were given a copy of their job description detailing their roles and responsibilities. Staff files provided evidence of vocational training in service related areas, e.g. moving and handling, food hygiene, safe administration of medicines and fire safety. Training needs were identified during supervision and the home provided ongoing refresher training. Staff told us they have the opportunity to complete the NVQ in care and currently more than half the care staff hold the NVQ2 in care. Staff were caring and approached residents in a polite and respectful manner. Residents told us that staff were “ kind and caring”, “very helpful” and “quite friendly”. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe, well managed and run in their best interests. EVIDENCE: The manager reported that she has completed the NVQ Level 4 in Management. The manager has considerable knowledge and experience of running a care service for older people. They had a good understanding of the conditions and illnesses that are associated with old age and was able to address such issues quickly, benefiting the residents. Her background also clearly demonstrated that she had the knowledge and skills to provide a service that was also culturally appropriate. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 22 Staff and residents told us the manager was accessible and had an ‘open door’ policy. Staff told us the manager gave support and encouragement in relation to career progression. They told us in the AQAA that all staff attend suitable training that will enhance the quality of life for residents. Quality Assurance checks are completed at the home and this identifies any areas which may require attention. Staff told us that they are always told when a significant change in residents needs has been made and what it says. The manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to improve further. They told us that they have a quality assurance system that has been introduced and that residents and their relatives or friends are sent questionnaires as part of the quality assurance process. Comments from staff about the management of the home included “she is very good very supportive” and “I would take concerns to manager”. A relative or friend told us “the manager is really good she is always here to talk to if I have any concerns” and “it is much better now A is here she is always ready to listen”. Visitors told us “it has been much better since A has arrived, she is really good with the residents and they all love her” and “couldn’t be in better hands”. We observed a number of residents and visitors come to the office to speak to the manager. Residents’ concerns and queries were given priority over the inspection visit, which is good practice. It was evident that the manager has a good relationship with the residents of the home. We saw the manager going to residents individually to ask how they were and spend some time talking to them. They told us for residents who do not hold their own personal allowances the home has a record of all transactions made and receipts are kept. Family members usually help residents to manage their finances; where this is not possible they would find an advocate to assist. A health and safety policy was in place and risk assessments of the premises and safe working practices had been carried out. This was to ensure that both residents and staff had relevant information to enable them to live and work in a safe environment. Fixed Gas and Electricty appliances had been regularly maintained and a periodic test of portable appliences and lifting equipment had been carried out and good records are kept. These checks mean that the safety of residents, staff and visitors was given priority. Accidents are recorded in the homes accident book completed; reports are Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 23 removed and stored in the individuals file in accordance with the Data Protection Act. Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. 2. 3. Refer to Standard OP7 OP7 OP9 Good Practice Recommendations It was recommended that daily records reflect the care delivered to residents. It was recommended that the risk assessment be adapted to clearly show the risk and the action needed to minimise those risks. In order to avoid errors, where medication is dispensed in an outer box and inner container the inner container should be labelled. It was recommended that the procedure used to refer any incidents of abuse is copied and displayed so that all staff are aware of the procedure. It was also recommended that they develop a flow chart of what action to take as an easy guide for staff. 4. OP18 Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cleggsworth Care Home Ltd DS0000068123.V365673.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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