Inspection on 14/05/08 for Clifden House

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Good service.

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

Clifden House 23/05/07

Clifden House 08/11/06

Clifden House 08/05/06

Clifden House 25/11/05

Clifden House 17/06/05

Clifden House 03/12/04

Clifden House 11/06/04

Clifden House 19/05/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Clifden House 82-88 Claremont Road Seaford East Sussex BN25 2QD Lead Inspector Melanie Freeman Unannounced Inspection 14th May 2008 09:30 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 Clifden House DS0000021423.V363289.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. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifden House Address 82-88 Claremont Road Seaford East Sussex BN25 2QD 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) 01323 896460 01323 896518 office@clifdenhouse.co.uk Mr Nial Joyce Vacant Care Home 52 Category(ies) of Dementia (0) registration, with number of places Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) The maximum number of service users to be accommodated is fiftytwo (52). 23rd May 2007 2. Date of last inspection Brief Description of the Service: Clifden House Comprises of four adjoining properties situated in a residential; area within walking distance of the seafront and local shops. The home is registered to care for 52 older people with Dementia. Resident’s private accommodation is provided on two floors, which includes five rooms that are registered for shared/double occupancy. All bedrooms are equipped with a call bell and a passenger lifts provide level access to the first floor. Most bedrooms have en suite facilities. The garden is secured however needs further landscaping to be fully enjoyed by residents and visitors. The service provides prospective residents and their families with a welcome pack, which includes a copy of the service users guide, and the statement of purpose the last inspection report is also available in the home. Fees charged as from 1 April 2008 range from £410 to £625. These are dependant on the room to be occupied and the level of care an individual may need. All personal items like books newspapers magazines are charged for along with additional services like chiropody and hairdressing. Intermediate care is not provided at Clifden House. Clifden House DS0000021423.V363289.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 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Clifden House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with visiting health and social care professional. The allocated inspector spent approximately six hours in the home and was able to discuss matters with the appointed manager and supporting management team. During the assessment visits the inspector was able to spend time meeting with the staff, visitors residents and observing practice in the home. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth and the inspector ate a midday meal with the residents in the dining room. The required Annual Quality Assurance Assessment (AQAA) was completed by the registered manager and returned when requested and was used to inform this inspection report. As part of this key inspection a thematic sample was completed which looked at the systems in place for the safeguarding vulnerable adults. This information is being used as part of a wider study that the CSCI is completing. What the service does well: All feedback received about the home reflected a good satisfaction with the care provided and the caring approach of the staff. Health and social care professionals now have a confidence in the home that they meeting residents needs. The home has a friendly atmosphere that encourages people to relax with staff having a good rapport with residents. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 6 Staff training is well organised and staff said that they liked working in the home and were supportive of the increased training in the home. The care documentation is informative, and staff were found to be professional in their approach to residents handling situations caused by dementia with understanding and patience. The quality and standard of the food was found to be good and to provide choice and variety. What has improved since the last inspection? What they could do better: Although the care documentation has been improved it still needs to reflect the specific care needs of residents and take into account residents and their representatives views. The systems for handling medicines need to be further improved to ensure accurate, clear and up to date record keeping. Clifden House does not provide a comfortable environment for all residents. A full schedule to address all shortfalls needs to be written with timescales. With Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 7 priority being given to ensuring the safety and comfort of residents living in the home currently. This schedule then needs to be adhered to. The home needs to ensure that practice in the home ensures that the risk of cross infection is kept to a minimum. Suitable hand washing facilities need to be provided to all communal hand washing areas that include liquid soap and paper towels. In addition the laundry facilities need to be appropriate to ensure all laundry is handled in a way to prevent cross infection. 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. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 8 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 Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 9 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, 3 and 6 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensure that all prospective residents are fully assessed by a competent person before admission and are assured that their needs can be met by the home. This process ensures that the home admits only those residents whose needs can be met by the home. Intermediate care is not provided at Clifden House. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 10 EVIDENCE: A copy of the homes statement of purpose and service users guide is available on request along with the last inspection report. Although the statement of purpose and service users guide were found to be informative they still need to be further updated to provide accurate and all the required information. It was noted that these documents referred to nursing care. The home is currently applying for registration to provide nursing care and need to ensure that the documents used reflected the current registration of the home. Required information that needs to be included is the size of rooms in the home and a full complaints procedure. The appointed manager has agreed to ensure that the necessary amendments are made. An assessment of the admission process included a review of the documentation used in respect of three recent admissions to the home. This demonstrated that all prospective residents are fully assessed prior to admission although it was noted that the documentation used is not always dated or signed. This brought to the attention of the assessor and the appointed manager who agreed that further attention would be given to completing documentation completely and accurately. Although prospective residents and their representatives are told verbally if the home is able to meet their needs following their assessment this is not currently confirmed in writing. This was discussed with the appointed manager who confirmed that this would be completed in the future. Contact with a resident’s relative and a visiting health care professional confirmed that the admission process was responsive to the individuals needs. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 11 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individual plans of care set out resident’s personal, health and social care needs with risk assessments being used to inform this plan. Resident’s health care needs are met with the advice and support of community health care professionals. The homes practice in respect to medicine administration could put resident’s at potential risk. EVIDENCE: The care documentation pertaining to three residents were reviewed as part of the inspection process and each of these residents were seen during the inspection visit to the home. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 12 Each resident had a plan of care and these were found to be informative providing clearly recording the residents care needs and providing guidelines to staff, and on the whole promoted a person centred approach to the care with resident’s individual choices being recorded. It was however noted that most of the plans of care were based on templates that are not always amended to reflect the specific individual needs of residents. The management team are aware that the plans need to be further developed to reflect a truly person centred approach. Records indicated that the plans of care are reviewed regularly, daily records are not always completed and in discussion the appointed manager confirmed her expectation that an entry would be made every 24 hours as a minimum. Staff need to be reminded of this responsibility and this will ensure an accountability for daily care is recorded. Individual risk assessments are completed that include nutrition, risk of falls, moving and handling and pressure sore development. There was evidence that these risk assessments are responded to appropriately to promote good standards of care and individual social plan based on discussion with the resident and their representative is also recorded. None of the plans of care recorded that residents or their representatives had been consulted about the care to be provided. This shortfall was discussed with the management team. All residents spoken to were very satisfied with care provided at the home and this view was also supported by visiting relatives. There comments included ‘they look after my wife very well indeed’ ‘this home makes him happy they do so much with him’. Health and social care professionals were also positive about the care and commented on how their confidence in the home had increased. At the last inspection there was a number of shortfalls identified in respect to the handling of medicines. The appointed manager and another senior staff member have worked hard to address these matters with increased staff training and monitoring of the medicine practice, and the records including the homes own audit system demonstrated a great improvement in practice and reduction in inaccurate medicine records. However records seen during this visit indicated that staff were still signing in the wrong place for medicines therefore indicating that they are not following best practice and maintaining accurate medicine administration records. This could put residents at risk. In addition on examination of the controlled drug register it was identified that one record relating to Temazepam did not demonstrate when they had been disposed of. The home does not have any controlled drugs in the home currently. Both these concerns were raised with the appointed manager for her to follow up and address. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 13 During the visit the inspector was advised that a new medicine room is to be located on the ground floor and this will provide a new controlled drug cupboard. The homes management are keen to keep required medication of residents to the minimal and has worked with the local GP’s to review all prescriptions and has reduced the number of medicines used. They are aware that they need to work with the psychiatric team with respect to any anti-psychotic medicine. Practice observed confirmed that staff administered medicines directly from a mobile trolley and that good practice was followed at this time. Clifden House was found to have a very good atmosphere, which was inclusive of residents, who were involved in any banter in the home. Both staff and residents and indeed visitors were seen to be enjoying each other’s company with residents being treated and recognised as individuals and not being controlled. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to make a range of choices about their lives and are helped in maintaining links with friends, relatives and the community. Resident’s benefit from staff providing stimulation, which includes leisure and recreational activities in and outside of the home. Residents receive a wholesome and appealing diet and are provided with choice. EVIDENCE: The home employs two activity people who work closely with the care staff to promote stimulation and activity in the home. New social care assessments have been completed and give a personal understanding of what residents like and do not like doing with some personal history. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 15 Residents spoken to said that there was lots for them to do in the home and commented on outings and activities that they had completed recently. One of the activity people was working in the home at the time of this visit and was seen to be well received and liked by residents who were laughing with her and enjoying her company. The home was found to promote humour at all levels. Visiting is encouraged and all visitors spoken to said that they were comfortable coming into the home and that there were areas in the home where they could see their relative in private. Choices are well respected with many of these being recorded in the care documentation. A meal was eaten with residents and a choice was given to residents who said this was always available. Mealtimes are not rushed and residents were able to have breakfast when they wished. Comments about the food were positive with residents saying ‘the food is always good’. Staff were particularly attentive with regard to providing residents with drinks and these were seen to be offered frequently. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 16 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that any complaint would be listened to and responded to appropriately. Staff training and information in the home ensures that any Safeguarding Vulnerable Adult issue would be responded to appropriately when identified. EVIDENCE: The homes complaint procedure has been updated since the last inspection and now needs to be readily available to all interested parties. When asked residents spoken to said that if they were concerned or felt unsafe they would talk to an identified staff member two did not know her name but identified one of the management team the other resident named the deputy manager. All visitors spoken to were also confident about raising any concern and said that they would speak to the deputy manager who is readily available. The home has dealt with three complaints raised, these have been investigated and responded to and records could demonstrate the action taken to resolve them. A concern raised by Social Service around medicines has been investigated and resolved however this issue was not recorded as a complaint/concern and therefore did not demonstrate that the home was using Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 17 information to improve their service. In addition the home correctly referred a safeguarding vulnerable adult concern but again records did not provide evidence that such matters were being used to inform practice in the home. This was discussed with the management team and the appointed manager said that in future all concerns/complaints and safeguarding issues would be recorded centrally to evidence how they are used as a quality monitoring and improving tool. The safeguarding alert raised by the home was not reported to the Commission and the acting manager was reminded of her responsibilities in reporting such matters. All staff spoken to and files examined confirmed that Criminal Records Bureau and Protection Of Vulnerable Adults checks are completed before employment. Records and discussion with staff confirmed that all staff have received training on Safeguarding Vulnerable Adults since the last inspection. This is now provided on a rolling programme and includes reference to the homes whistle blowing policy. Staff interviewed demonstrated a good understanding of adult abuse issues. The homes policy and procedures on Safe Guarding Vulnerable Adults and whistle blowing need to be updated and need to be cross referenced with the new local procedures which were discussed with the appointed manager. She said that this would be completed and that any staff training in the future would reflect these. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 18 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): 19 and 26 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment does not ensure all resident’s benefit from a comfortable well-maintained and equipped safe home. On the whole the home is clean however areas that are in a poor decorative order are difficult to clean adequately. EVIDENCE: Clifden House is a converted premise that has been extended and adapted to its present use of many years. On arrival the home the front entrance area was bright and inviting and a warm welcome was afforded. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 19 Resident’s accommodation is found on the ground and first floor and disabled access is provided throughout the home via passenger lifts and ramping. One area of the garden has been landscaped and is very attractive, however most of the garden to the front and rear of the property is unattractive and does not provide a safe area for residents or their visitors. One relative spoken to said that he had been waiting for a suitable garden area to take his wife to for a very long time and it was still not available. A tour of the home confirmed that the home smelt fresh throughout. The recently refurbished part of the home, which includes 16 single rooms with en suite facilities and suitably equipped bathing facilities, was well appointed and provides very good facilities. However other areas in the home need major refurbishment, some occupied rooms were found to have bare walls where the skirting boards have been removed. Even in areas that were said to have been refurbished a number of shortfalls were identified for example; • A double room was found not to have an extractor fan in the en suite although a hole was in the ceiling ready for it, an aerial wire was hanging without a metal end, the lock on the en suite was broken. • A single room was found not to have a toilet roll holder, mirror, towel rail, bathroom cabinet, or a working extractor fan. Although there is a schedule of building works to be completed in 2008 there needs to be a thorough planned work schedule that takes into account all the works to be completed with time scales. This needs to ensure minimal disruption is caused to residents and that all residents live in a comfortable safe environment as a priority. Discussion with the appointed manager confirmed that she and the deputy manager would tour the home in detail and provide a thorough list to cover all areas that need attention. The home has various communal areas that can be used for different activities and allows residents to move freely in space. Visitors said that they liked to have the opportunity to sit with their relative in a quiet area and to mix with other residents as they wished. On the whole the home was found to be clean however in some areas where upgrading and refurbishment was waiting to be progressed the cleaning was not good an example of this is the communal room known as number 14. The tour of the home also highlighted that in communal hand washing areas tablets of soap were available and in use. This was raised with the management team and the risk of cross infection discussed. Suitable hand washing facilities needs to be provided in all communal hand washing areas. The laundry room was also viewed and it was noted that this was very small and that there was only one washing machine and dryer. The size of the room Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 20 made it difficult to separate clean from dirty linen. This facility was also discussed with appointed manager along with the need to review to ensure best infection control practice is followed. This concern will be further compounded when the occupancy of the home increases. During the inspection visit residents were seen to be in clean and well-ironed clothing. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 21 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix provides a competent and well-motivated staff team that meets residents health and personal care needs with a commitment to staff training. The homes recruitment practice was found to be robust. EVIDENCE: At the time of this inspection visit the home was occupied by 40 residents and staffing levels observed was found to be appropriate to meet the needs of residents, and records held by the home confirmed that these levels are maintained over the week. Staff and relatives spoken to thought that there was enough staff to look after the residents well. All feedback received about the staff working in the home was very positive and comments received indicated that the staff truly cared one visiting professional said that she was impressed with how the staff went beyond what would normally be expected in order to meet one residents care needs. Residents were said how they liked the staff and how ‘kind and sensitive’ they were. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 22 Discussion with the appointed manager confirmed that the home has a commitment to supporting staff through their National Vocational Qualification with over 77 of staff attaining an NVQ at level 2 or above. Information provided and discussion with staff indicates that a programme of training is in place that includes health and safety topics, abuse awareness and training specific to the needs of residents with dementia. The home employs a training co-ordinator and outside consultant trainer to progress and organise this training that also ensures a suitable induction that complies with the skills for care standards is completed. A training matrix was available to demonstrate the training provided. Staff indicated that one of the most positive things about working in the home was the availability and content of the training. The recruitment practice in respect of four staff members was reviewed and were found on the whole to be full, records checked included an application form, two references and the necessary Protection Of Vulnerable Adults and Criminal Records Bureau checks had also been obtained. Recruitment practice could be further improved with greater attention to ensuring a full employment history is supplied and references include the last or current employer. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 23 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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management arrangements provide clear leadership and an appropriate management structure. Systems for monitoring the quality of care take account of resident’s views. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 24 EVIDENCE: A new manager was appointed in June 2007 and she advised that her application for registration is being progressed by the registration team of the Commission for Social Care Inspection. She is a registered nurse with the Registered Managers Award and has been a registered manager in another care home. She originally worked in the home in a consultative capacity improving the care documentation and the policies and procedures. She is well supported by the deputy manager and team leader who make up the management team. She has provided a strong leadership and direction to the home since her appointment. The home holds a bank account for small amounts of monies on behalf of those living in the home and full records of all transactions are kept. It was however noted that receipts are not used for deposits made by relatives and this was raised with the deputy manager who is responsible for these accounts. She confirmed that she would use receipts in the future and that a clear procedure would be put in place to set out the system in place, to safeguard staff and residents monies. The appointed manager completes regular audits in respect of medicine handling, training and care documentation, and has completed a report based on residents satisfaction questionnaires completed this year. The registered provider visits the home each month and an Annual Quality Assurance Assessment was completed by the home as required by the Commission. The home has a maintenance person and systems are in place for him to respond to any maintenance issue raised by staff in the home. He completes regular safety checks and procedures are in place to underpin and ensure appropriate health and safety practice is followed in the home. Records indicated that staff receive regular training on health and safety matters and that the manager completes regular environmental risk assessments. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 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 Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP7 Regulation 15 Requirement Plans of care must be composed and reviewed with input from the resident and or their advocate, unless the offer is declined. That all medicine records are clear, accurate and up to date. The registered provider needs to provide a schedule of works to address the necessary upgrading and redecoration to ensure all areas of the home are kept in a good state of repair internally and externally, and are reasonably decorated to promote resident safety and comfort. This should identify timescales for completion and be provided to the commission. 4 OP26 13(3) Suitable hand washing facilities need to be provided in all communal hand washing areas that include liquid soap and Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 27 Timescale for action 01/08/08 2 3 OP9 OP19 13(2) 23(2) 01/06/08 01/07/08 01/07/08 paper towels to promoted good infection control practice. 5 OP26 13(3) The registered person needs to 01/07/08 review the laundry provision in consultation with the Environmental Health Officer/Health Promotion Agency to ensure suitable facilities to deal with all the laundry and to prevent any cross contamination. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations That the home is assessed by an Occupational Therapist to ensure the facilities, adaptations and equipment throughout the home is suitable to meet the resident’s needs. Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Clifden House DS0000021423.V363289.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!