Inspection on 25/08/05 for Clevedon House

This inspection was carried out on 25th August 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 but made no statutory requirements on the home.

Other inspections for this house

Clevedon House 16/02/07

Clevedon House 15/03/06

Clevedon House 03/02/05

Clevedon House 27/07/04

Clevedon House 18/09/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Clevedon House 70 Clevedon Road Weston Super Mare North Somerset BS23 1DF Lead Inspector Catherine Hill Announced Inspection 25th August 2005 10:30 Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 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 Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 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. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clevedon House Address 70 Clevedon Road Weston Super Mare North Somerset BS23 1DF 01934 624836 01934 624836 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) Freeways Trust Limited Miss Victoria Hoar Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2005 Brief Description of the Service: Clevedon House is part of the Freeways Trust and is a community home for people with a learning disability. It is situated in a quiet residential area of Weston, close to local amenities, the seafront and the town centre. The home is two converted semi-detached Victorian houses. Most of the residents are in their forties or fifties, although a couple of people are over retirement age. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted during the course of one day from the late morning until the late afternoon. The early part of the inspection focused on going through the requirements of the Care Standards Act 2000 with the new acting manager and on checking records. From late lunchtime onwards, the inspector spent time talking with residents and staff, either in the communal rooms or privately. The previous manager, who had been at the home for about a year, had left not long before this inspection and been replaced by the current acting manager, Shelley Holvey. This transition was made much smoother for everyone by allowing a good handover period while the two managers worked alongside each other. Ms Holvey has worked with Freeways for some time and was already known to some of the residents. She has experience in managing another home. Eight of the residents and two of their visitors had completed CSCI comment cards prior to this inspection. People s comments on these cards were very positive, and this was echoed by many of the comments that residents made to the inspector in person. Residents have interesting work or vocational day placements, and the staff team is continuously looking at ways of giving residents more control in their own home. Staff also felt very positive about working at the home, and particularly like its relaxed and friendly atmosphere. What the service does well: What has improved since the last inspection? There has been an improvement in the regularity with which the monthly key worker reports are being kept. These reports are both a monthly health and welfare check written with the residents themselves, and a review of the person s support plan, so it is now much easier for the team demonstrate that each persons needs are being properly assessed and met. One member of staff with particular interest in this area has been delegated responsibility for carrying out fire precautions equipment checks and staff fire Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 6 training. The fire precautions records showed that the Fire Officer s recommendations are now being met. The builders rubbish that was in the front garden at the time of the last inspection has been moved, and proper storage for household rubbish has been provided. The bedrooms that really needed attention have been redecorated. What they could do better: Two requirements were made at the last inspection that have still not been met: • bathing facilities must be provided that suit residents needs. Freeways Trust hoped to complete work on an upstairs shower by April of this year, but this has not yet been done. • suitable sleeping-in facilities must be provided. Proper doors have been provided to the activities room, where the second member of staff sleeps in, rather than the curtains that were there before. While this gives the staff member more privacy, it is still not satisfactory as this is a communal room for residents use. Bathrooms and toilets were clean but scruffy, and need attention. The additional shower that was due to be installed shortly after the last inspection has still not been fitted. While residents generally described good, equal relationships with staff, a few comments were made that indicated there may be a couple of staff who still tend to talk to residents in an over-directive way. The inspector noted in her last report that relationships may become strained if residents still wish to use the activities lounge after the sleeping-in staff member wants to go to bed, and that providing a proper sleeping-in room for the second person should resolve this. The acting manager was already aware of some potential issues between residents and staff, and is addressing them in staff supervision sessions. In the meantime, the requirement to have suitable sleeping in facilities must still be met. There has been a number of medication errors recently, despite repeated training for staff. The acting manager is monitoring this in conjunction with another Freeways manager who has particular responsibility within the organization for ensuring medications good practice. There is a good will within the team to improve residents quality of life but this is not always translated into practice. As examples of this: • While the regularity of key worker reviews has greatly improved, many of those sampled showed the same needs being raised month after month but no clear plan of action to meet them. These plans should include specific actions, set timescales, and named people who are Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 7 • responsible for carrying them out. The reason for plans not being carried out should be recorded in the next month s key worker review. Residents meetings are held every few weeks, and the minutes showed that staff encourage residents to contribute their ideas to the running of the home. However, there is no indication in the next meetings minutes of what action has been taken to address the issues previously raised by residents. There has been an ongoing problem for some years with the conservatory roof. Freeways Trust has been working with the architect and contractor to resolve this, but rain is still coming in. It has been a requirement of every inspection that the room is redecorated and the carpet replaced once the roof leak has been sorted out. However, the poor state of this room must be remedied now. The carpet beneath this roof is very badly stained, the walls require redecoration, and blinds must be fitted to the roof windows. 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. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 8 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 Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1 Prospective residents and supporters get information about the home before they visit, but the information on staff requires updating. EVIDENCE: The homes Statement of Purpose has been updated to show the change of manager, and to give information on her experience and qualifications. However, it needs a bit more updating regarding recent staff changes. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 10 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 the following standard(s): EVIDENCE: These standards were not fully assessed at todays inspection. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 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 the following standard(s): 11-14, 16 & 17 Each person is supported to pursue social and vocational activities that interest them, and gets good opportunities to lead a fulfilling life. EVIDENCE: The residents noticeboard contained a lot of useful information on local events and clubs. The minutes of recent residents meetings were also posted here and these included the current programme of activities and outings, and a list of activities planned for the near future. Several of the residents have part-time work in the community. This evidently gives people the sense that they are contributing something worthwhile as well as creating opportunities to make good social links outside their home. Some of the residents mentioned their life skills days - where they spend oneto-one time with their key worker, pursuing their individual goals - as particularly enjoyable and rewarding. Residents are also encouraged to arrange their own leisure time, and a couple of people were going to the theatre together that evening. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 12 One person who has gone through a particularly difficult time lately gave a number of examples of how staff have tried to make things easier, and how accommodating the team has been. The home is looking into acquiring a voice-activated computer programme so that the residents can take over responsibility for writing up the minutes of their meetings. The home intends to record these on rewritable CDs so that each person can borrow a copy to listen to the minutes if this is preferable to reading. Residents are encouraged to contribute their ideas to the menus, and each weeks menu is posted on their noticeboard. One person commented that menus have changed recently, following a residents meeting. Residents felt that staff are all good cooks. Although many of the residents are quite capable of helping with meal preparation and of observing the requirements of good food handling practice, the inspector noted that staff prepared meals without residents help. This is quite a significant area of life in which residents could be given more control, and it is recommended that the team consider ways of achieving this. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 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 the following standard(s): 20 Although medication procedures are well designed, they are not proving effective in eliminating errors. EVIDENCE: Freeways Trust operates a particularly detailed and thorough medications procedure. However, there has been a number of medication errors recently, despite repeated training for staff. The acting manager is monitoring this in conjunction with another Freeways manager who has particular responsibility within the organization for ensuring medications good practice. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22 & 23 Effective procedures are in place for protecting residents, and the staff team is working hard to create a culture in which residents views are listened to and respected. EVIDENCE: Freeways Trust has a comprehensive adult protection procedure, in line with North Somerset Social Services No Secrets guidance. The previous manager did a lot of work on complaints with the resident group, and staff have started completing Listen to Me books with some of the residents. These books are intended to support person-centered planning and provide a further means of finding out how each person wants to be supported. There is a welcoming and informative complaints procedure, and a pictorial version is available to the residents. A complaints form is about to be brought into use, rather than the book, so that each complaint can be kept confidential if necessary. No complaints have been received by the CSCI. While the regularity of key worker reviews has greatly improved, many of those sampled showed the same needs being raised month after month but no clear plan of action to meet them. These plans should include specific actions, set timescales, and named people who are responsible for carrying them out. The reason for plans not being carried out should be recorded in the next month s key worker review. Residents meetings are held every few weeks, and the minutes showed that staff encourage residents to contribute their ideas to the running of the home. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 15 However, there is no indication in the next meetings minutes of what action has been taken to address the issues raised by residents. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 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 the following standard(s): 24-30 In general, the environment is well-suited to residents needs and lifestyles. However, some specific areas require attention. EVIDENCE: The home is made up of two semi-detached houses, and blends in with the neighbouring properties. There is a pleasant dining area leading off the main lounge and next to the kitchen. The French window from the lounge leads out to the back garden. There is a smaller television lounge and an activities room just off the main lounge. In most ways, Clevedon House provides a comfortable and pleasant environment for its residents, but there are a few significant matters that are below the acceptable standard. There has been an ongoing problem for some years with the conservatory roof. Freeways Trust has been working with the architect and contractor to resolve this, but rain is still coming in. It has been a requirement of every inspection that the room is redecorated and the carpet replaced once the roof leak has been sorted out. However, the poor state of this room must be remedied now. The carpet beneath this roof is very badly stained, the walls require redecoration, and blinds must be fitted to the roof windows. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 17 Although bathrooms and toilets had been thoroughly cleaned, they all needed a lot of attention to bring them up to a satisfactory standard. Mastic around baths is disintegrating and badly mildewed, as were the rubber bath mats, and walls and ceilings are stained or patchy. There is a lumpy patch of hard glue on the tiles in the second floor bathroom where the old soap dispenser was, and in several of the bathrooms there were parts of broken towel rails on shelves or behind doors. The handbasin pedestal of the downstairs toilet near the front of the house has been removed, leaving an unsightly area exposed. These rooms must be decorated and made good. The bathing log on the wall of the first-floor bathroom was dated June 2005 and had not been completed. There was a similar document on the wall of the second floor bathroom, dated January 2005 and also uncompleted. It is good practice for staff to record the hot water temperatures of those residents who need support with bathing, and these records are worth keeping up-to-date. Alternative methods of keeping note of this information were discussed. While residents generally described good, equal relationships with staff, a few comments were made that indicated there may be a couple of staff who still tend to talk to residents in an over-directive way. The inspector noted in her last report that relationships may become strained if residents still wish to use the activities lounge after the sleeping-in staff member wants to go to bed, and that providing a proper sleeping-in room for the second person should resolve this. The acting manager was already aware of some potential issues between residents and staff, and is addressing them in staff supervision sessions. However, it is not satisfactory to use a communal room as a staff sleeping-in room, either from the residents point of view or the staffs, so this requirement is still outstanding. Ms Holvey is looking at the possibility of reorganizing the two adjacent small offices and of using one of these as a sleeping-in room. There is a very old mirror on the second-floor landing whose frame and glass are extremely worn. The glass is so patchy that it is difficult to see a reflection in it. The inspector suggested that the occupants of the two rooms on this floor are asked about the mirror and whether they would like it replaced. At the time of the last inspection, the home planned to do some work to the back garden to make it more suited to the residents lifestyle. This had not been carried out by the time of todays inspection, but there is a large hole at the end of the garden where a pond was planned. The acting manager is aware of the potential danger this poses, and told the inspector that staff and residents will be carrying out the necessary work on the holiday Monday following this inspection. Many of the fire doors are fitted with magnetic door closes, so that they can close freely if the fire alarm sounds. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed at todays inspection. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 The home is well run, and the acting manager and team are working with the residents to create an empowering culture. EVIDENCE: There have been a number of changes of manager over the past few years, and Shelley Holvey has recently taken over as acting manager. She has experience of managing another Freeways home and is currently applying to be registered manager of Clevedon House. The organisation has a strong commitment to empowering the people who use its services. As an example, one of the residents is currently paid for the cleaning work she does around the home. Freeways Trust paid for her to do her NVQ 1 in cleaning, and are looking into getting pension rights for her. Also, Freeways is introducing picture- and symbol-supported policies to make them more accessible to residents, but also intends recording these on to CDs so that people can listen to them. Freeways Business Plan and Strategy is Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 20 also supplemented by pictures, to be more accessible to the people who use its services. Residents are responsible for a number of household chores around the home, and agree a rota between them. Individual staff also take on responsibility for particular aspects of the running of the home, according to their interests and special skills. Each member of staff has rostered office time to allow them time to write up reports. Residents and staff meetings are held regularly, and an agenda is posted on the office noticeboard to which anyone can add items for discussion. One of the staff now has delegated responsibility for carrying out fire precautions checks and fire training in accordance with the Fire Officers recommendations. The fire precautions log book shows that these checks are now being kept up to date and that staff are receiving regular refresher training. A monthly health and safety check of the environment is also carried out. Freeways has comprehensive health and safety policies and risk assessments on site. The Freeways line manager with responsibility for this home visits unannounced at least every month, and spends time talking with residents and staff about the quality of service provided. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 21 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clevedon House Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000008083.V261729.R01.S.doc Version 5.0 Page 22 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 2 Standard 1 24 Regulation 4 23 Requirement The Statement of Purpose must be updated to show recent staff changes. The conservatory lounge must be redecorated and recarpeted, and blinds must be fitted to the roof windows. Bathrooms must be suited to residents needs and lifestyles. Timescale for action 25/09/05 25/12/05 3 27 23 25/01/06 4 28 23 This requirement was first made at the inspection of 03/02/05. An additional shower is required, and at todays inspection it was noted that all bathrooms and toilets need redecoration. Suitable sleeping-in facilities 25/12/05 must be provided. This requirement was first made at the inspection of 03/02/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 23 No. 1 2 3 Refer to Standard 17 22 27 Good Practice Recommendations Ways of involving the residents in meal preparation should be considered. The quality assurance system needs to link residents stated views to clear action plans, which should be reviewed periodically. A record should be kept of the bath hot water temperatures of those residents who require support with bathing. Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Clevedon House DS0000008083.V261729.R01.S.doc Version 5.0 Page 25 - 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. 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