Inspection on 23/05/07 for Clifden House

This inspection was carried out on 23rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Clifden House 14/05/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clifden House 82-88 Claremont Road Seaford East Sussex BN25 2QD Lead Inspector Gwyneth Bryant Key Unannounced Inspection 23rd May 2007 08:00 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.V337211.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.V337211.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 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users must not exceed thirty six (36). Service users accommodated must be aged sixty-five (65) years or over on admission. Service users with a diagnosis of an early onset of dementia only to be accommodated. 8th November 2006 Date of last inspection Brief Description of the Service: Clifden House is a large detached house on two floors and provides two passenger lifts to access the first floor accommodation. The home is registered to care for 36 older people with Dementia. It is situated in a residential area of Seaford, with the seafront and town centre within short walking distance. The home is a member of the Alzheimer’s Disease Society. The home provides a light and airy dining room and four lounge areas. There is a large wellmaintained rear garden. The home provides 26 single bedrooms, 24 of which have toilet en-suite facilities and 5 double bedrooms with toilet en-suite facilities. Plans are in place to fit en-suite facilities to the remaining two single rooms. There are four bathrooms with assisted bath seats and six communal toilet facilities. Toilet riser seats, hand and grab rails are fitted as required. The service provides prospective service users and their families with a welcome pack which includes a copy of the Service Users Guide, a contract, terms and conditions, the Statement of Purpose, complaints policy, a copy of the latest inspection report and details of the trial periods offered. Fees charged as from 1 April 2006 range from £375 to £525, which includes toiletries, outings, activities and small items such as tights. Additional charges are made for hairdressing, chiropody and newspapers. Intermediate care is not provided. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 8.75 hours. There were thirty-four people in residence on the day. The inspector spoke with six people who live in the home, the Acting Manager, the Deputy manager and two members of staff during the day. One relative was spoken with at the time of the site visit; it was not possible to talk to other relatives after the site visit as the home did not provide contact details. The purpose of the inspection was to check that requirements of previous inspections had been met as agreed with the Registered Provider and to inspect other standards. A tour of the premises was undertaken and a range of documentation viewed including care plans, personnel and medication records. Five surveys were returned and comments included: ‘Excellent, sensitive standards of care’ ‘it (the home) gives the residents choice and permits them, when possible to be themselves’. ‘the notice board for day of week, weather, menus etc is not kept up to date so is confusing, even for visitors’. ‘my wife’s needs are very simple and she is cared for very well’. Those people living in the home who were able to express an opinion generally agreed that they enjoyed the food and the staff were nice. Comments from those spoken with included: ‘I like the food and (name) is ever so nice’. Prior to the site visit information was requested from the provider; this was given and information detailed is used in this report as necessary. What the service does well: What has improved since the last inspection? The Registered Provider has invested a great deal of money as part of the refurbishment programme, including a new kitchen, refurbishment of communal bathrooms and the provision of new fire doors to individual bedrooms. The development of the whole site is on-going as part of the extension programme. Work has recently begun on new care plan formats Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 6 that should enable staff to identify and plan for the care needs of those living in the home, including the reduction of risks related to falls and tissue breakdown. The use of wheelchairs without footplates has ceased and robust recruitment practices are now in place. The quality assurance and quality monitoring process has been expanded with internal audits being carried out for all policies and procedures, recruitment and staff training. 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. Clifden House DS0000021423.V337211.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 Clifden House DS0000021423.V337211.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): 3 and 4. Standard 6 is not applicable People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to people moving into the home which ensure that their needs can be met. EVIDENCE: Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used to ensure the home is able to meet the needs of those people admitted to the home. The Acting Manager stated that there is a plan to ensure that, in the future, the home receives a mental health assessment from the appropriate healthcare professionals to ensure all needs are clearly identified and planned for. The Acting Manager also confirmed that emergency admissions are only accepted if the individual meets the admission criteria. Intermediate care is not provided. The relative spoken with on the day confirmed they received detailed information at the time of admission and also a contract. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 9 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 the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Work on updating all aspects of service users health, social and care needs to be completed without delay and significant improvements must be made to the handling and recording of medication. EVIDENCE: Five care plans were viewed, including two for two people recently admitted to the home and the day and night notes for the two weeks preceding the site visit were also viewed. While there have been improvements in all parts of the care planning process there remains much work to ensure all care plans are complete and accurately reflect the needs of those living in the home and how they will be met. Those care plans that had been updated included direction to staff in the delivery of care, and the risk assessments now included how risks were to be reduced. People living in the home would benefit if the updating of care plans and risk assessments were completed without delay. The home continues to monitor those people who present challenging behaviour and these are detailed and clearly show techniques for effectively managing these behaviours ensuring that neither staff nor those living in the home are put at Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 10 risk. Those living in the home are weighed regularly but records indicated that one person had lost a considerable amount of weight. This was discussed with the deputy manager who believes that the differences were due to new scales being used but agreed to ensure weight continues to be carefully monitored. Daily notes indicated that one person had been manually evacuating her own bowels, leading to some bleeding, however there were no records of action taken to address this problem. One person had lost her false teeth and the Deputy Manager explained that this lady often hides them and although daily notes showed staff were aware of the loss there was no information in respect of action to be taken to ensure she is able to eat, nor who took responsibility for finding the teeth. The daily diary had a highlighted heading stating ‘No tights on residents today as the chiropodist is coming’. This indicates a task orientated service and the Acting Manager agreed it was inappropriate and that she would deal with it. Care plans showed that all updated ones included information on inappropriate behaviour even thought not all service users had displayed such behaviours. Again this was discussed with the acting manager who agreed that it was not appropriate to record potential behaviour and it should be relevant to the condition at the time of writing. The Acting Manager has carried out a detailed audit of medication but on the day of the site visit a number of errors were found such as correction fluid used in the controlled drugs register, some gaps in the medication recording chart, some signatures overwritten indicating that medication has been signed for prior to administration. A carer spoken with said that contaminated medication was being washed down the sink and this needs to be addressed to ensure there is a clear audit trail of all medication within the home. Medication charts indicated that one person was not given her dose of Warfarin and this also needs to be addressed as this particular medication is crucial to this persons well being. A secure drugs trolley has been purchased to enable staff to transport medication throughout the home, without putting people at risk. One lady was seen with two cuts to her forehead and a member of staff said she had fallen but there was no record of how the injury occurred. This was discussed with the Deputy Manager and Acting manager and neither were sure how the cuts had occurred and the Acting Manager said that maybe the carer assumed the lady had fallen, however she agreed to investigate as the lady in question has reasonably good mobility and does not have a history of falls Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 11 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): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by people living in the home does not always match their expectations, choice or preferences but they do benefit from a choice of meals. EVIDENCE: The daily diary had a highlighted heading stating ‘No tights on residents today as the chiropodist is coming’. This indicates a task orientated service and the Acting Manager agreed it was inappropriate and that she would deal with it. Care plans showed that all updated ones included information on inappropriate behaviour even though not all individuals had displayed such behaviours. Again this was discussed with the acting manager who agreed that it was not appropriate to record potential behaviour and all care plans should be relevant to the persons condition at the time of writing. Some of the information in care plans showed that individual needs in respect of privacy and dignity had been identified and met. The home has developed an activity programme and staff were seen to be encouraging service users to sing along. It was still disappointing to note that an activities co-ordinator has yet to be recruited and that one ‘activity’ was hairdressing. In addition there was no evidence that the activities provided were based on the preferences of Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 12 those living in the home. It was pleasing to see that night notes indicated that people living in the home are enabled remain in the communal areas and were given drinks and snacks as requested, even if this was in the early hours of the morning. A qualified chef has been recruited and is due to start in 3 weeks time – there is a plan to introduce new menus, including seasonal variations. The kitchen refurbishment is almost complete and the new appliances should facilitate the provision of a greatly improved menu. Already those living in the home are offered a cooked breakfast every day as well as cereals and toast. The menu was discussing with the Acting Manager who agreed that it needed much improvement, she also said there is a plan to implement the governments recommendation of five pieces of fruit and vegetables every day. The current menus are satisfactory and most people able to express an opinion said they liked the food, although one said ‘I never eat here as I don’t like the food’. Other comments were: ‘Its ok here – nothing to do so I just have a walk’. ‘Its very nice here – the food is good and we are fed well’ ‘Staff are very nice’ Comments from returned surveys included: ‘ I visit my father and there is never a restriction on times – I can go there whenever I like which is good!’ Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 13 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 the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a detailed complaints system with evidence that concerns are listened to and acted upon, those living in the home are further protected by satisfactory adult protection policies and procedures. EVIDENCE: The home has detailed policies and procedures on complaints and the complaints records received showed that any concerns raised are acted upon in line with those policies and procedures . Comments in returned surveys included: ‘I have not found that they have always responded to my concerns’. ‘ I feel that a regular support plan should be discussed with family members and with my father present’. The home has comprehensive policies and procedures on adult protection and the Acting Manager confirmed staff have been trained in Protection of Vulnerable Adults. The Acting Manager discussed a recent referral she made in respect of Protection of Vulnerable Adults and it was evident the matter was handled in line with the Protection of Vulnerable Adults guidance and the CSCI informed. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 14 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 the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some parts of the home are well maintained providing a homely and comfortable environment; improvements need to be made in respect of ongoing maintenance to ensure all areas of the home are pleasing, safe and free from offensive odours. EVIDENCE: On arrival there was very strong odour of urine throughout the home. This was discussed with Acting Manager who said the cleaner doesn’t come in until later. The strong odour in the mornings suggests that night staff may need to revise the process in respect of continence management. This was discussed with the Acting Manager who agreed to review the night routines. On touring the premises it was noted that two bathrooms had been superbly refurbished but the soiled waste bins did not have lids therefore these bathrooms were malodorous. Other parts of the home, including individual rooms and en-suite Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 15 facilities were also malodorous. The Acting Manager said that she felt the home could not meet the needs of some individuals therefore she would be requesting a reassessment. One of the small lounges has recently been refurbished and is now a pleasant and attractive place to sit for those living in the home. A carer was observed to leave an individuals room wearing gloves and apron then touching another person as she passed her then went back into the individuals room after collecting a towel. These practices place both staff and people living in the home at risk of cross infection and therefore must be addressed. A member of staff was seen to offer cake to a gentleman who lives in the home and saw he did not have a plate so took a used one from the pile of used plates on the trolley and put the cake on it before giving it to him. Again this is unacceptable practice and may result in cross infection. The garden area is attractive, well maintained with appropriate seating and provides an accessible and safe area for service users. Following the last inspection the registered provider produced a building programme that indicated certain en-suite facilities would be refurbished by May 2007 but this was not achieved, therefore the provider needs to ensure the refurbishment programme remains on target to ensure people living in the home are not at risk of infection due to unhygienic en-suite facilities as some en-suite hand basins needed to have sealant replaced and the wooden bases of toilet bowls are also likely to harbour bacteria. On the day of the site visit a number of bedroom doors were being replaced and although the carpenter said he ensures his tools and equipment are not left unattended this is not always possible as the nature of the work requires him to turn his back on the area where he leaves his equipment. A number of the people living in the home like to wander around the building and some were noted to take interest in the work. The issue of risk assessments for the building work was discussed with the Acting Manager and she said that she had not had time to do them as the inspection was taking place. It was noted that some doors had already been replaced so the risk assessment should have been in place for the carpenters’ second visit. Call bells were not provided in one shared room and this was discussed with the Deputy Manager and the Acting Manager who thought that one of the people living in the home may have removed them. It is important to monitor this as it is crucial that people living in the home can contact staff in an emergency. Comments from returned surveys included: ‘light bulbs in rooms need changing when necessary’. ‘drawer units are broken and quite dangerous’. ‘need to return clothes from the laundry to the individuals’. ‘ I would like to see the garden and garden furniture upgraded’. ‘the home at the present is being extended and there have been some quite unsafe situations – with contractors working in corridors’. ‘ I am not sure the new chairs (although thankfully now plastic covered and therefore wipeable) are very comfortable for either residents or visitors’. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 16 ‘missing clothes, lack of shoes and socks etc have all been taken care of adequately’. ‘the current refurbishment programme will take care of the slightly ‘down at heel’ feel about parts of the home and its furniture’. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 17 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 the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recruitment and training is robust and thorough and ensures those people living in the home are not at risk. EVIDENCE: Following the site visit the acting manger confirmed that of the 20 Care assistants 7 have at least National Vocational Qualification level 2 in care and two have just been enrolled on this course. There is a plan to enroll additional staff when they are recruited. Two staff were enrolled following the site visit therefore the home is on target to have 50 of care staff with this qualification. The staff rota showed that there are six carers on the morning shift and at least five during the afternoon and evening shifts. Three night waking staff are also employed. The Acting Manager explained that she is in the process of reviewing the staff structure with a view to employing trained nurses to assist with the care planning process, risk assessments and staff supervision. The Acting Manager has also carried out an audit of the recruitment process and some of the staff training and identified a number of shortfalls in both processes. She has developed a plan to address them in a timely fashion to ensure those living in the home are safe and staff have the skills to deliver good quality care. The records for the two staff due to start were viewed and found to include all the required checks to ensure those living the home are not at risk. The Acting Manager also confirmed that the home has a staff induction programme that meets the skills for care guidance and she has just Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 18 completed a staff handbook which provides a point of reference for all staff in respect of the homes policies and procedures and staffing arrangements. Comments in returned surveys from relatives included: ‘the care staff are wonderful’ ‘ I am very happy with the care my mother receives at Clifden House’ ‘they do their best to keep him clean and content – not an easy task’. ‘the staff have a very difficult job trying to give the appropriate level of support to each of the residents with their differing behaviour patterns and level of need’. ‘the staffing level often seem too low for them to be able to cope’. ‘ they (staff) have, in the main been very kind and caring’. ‘on the whole the care is excellent. There has been the odd occasion when no member of staff was present to keep an eye on a large group of clients – some quite active – ‘situations’ develop quite quickly’. ‘on the whole the staff are conscientious and eager to please’. ‘there have been instances in the past when certain staff members’ behaviour has seemed inappropriate (loud shouting et). I gather these people are no longer at the home – the remainder of the staff are a caring and kindly group’. ‘unscheduled visits to Clifden House have confirmed that the current staff members treat the clients with great kindness and respect.’ Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 19 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 the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although adequate systems are in place to protect service users financial interests, all aspects of the health, welfare and safety of people living in the home need to be protected and promoted EVIDENCE: The Acting Manager confirmed she has an appropriate care and management qualification that meets the required standards. She has worked part time in the home in a consultative capacity since December 2006 prior to becoming the Acting Manager at the beginning of May 2007. She is in the process of reviewing a range of documents to ensure they accurately reflect working practices in the home. 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. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 20 One person spoken with said that she never had any money, not even enough to buy a bar of chocolate, however the Deputy Manager confirmed that she ensured this person had £5 on her at all times. At the last site visit this same person said she would like to go to the shops, however, there was no recordes to show this had occurred and this needs to be addressed. There is now a comprehensive Control of Substances Hazardous to Health risk assessment in place to ensure neither staff nor service users are at risk. A carer was observed to attempt to assist a lady to get out of a chair by holding her under the arm, whilst steadying her Zimmer frame with her foot. On noting she was being observed the carer then called another carer and used an appropriate lifting belt. This was discussed with the Deputy Manager and the Acting Manager both of whom confirmed that all staff have been trained in manual handling techniques so there is a need to ensure that staff put this training into practice. One person was seen to have a two cuts on her head but neither the Acting Manager nor the Deputy Manager were able to explain how the injury occurred as there were no records relating to this. Where the cause of an injury is not known it action taken to treat the injury needs to be recorded and a risk assessment carried out to ensure the risk of further injury is reduced. Information in the pre-visit document confirmed that safety checks are carried for all gas and electrical appliances and a detailed fire risk assessment has also been done. For the quality assurance the Acting Manager has done audits of medication, care plans, Control of Substances Hazardous to Health, recruitment and staff training and the registered provider visits the home each month, with the subsequent reports available for inspection. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 21 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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 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 2 Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 3 4 Standard OP7 OP9 OP9 OP9 Regulation 13 (4) (c) 13 (1) (b) 13 (2) 13 (2) Timescale for action That action is taken when service 23/06/07 users are acting in ways that cause self-harm. That prompt action is taken 23/06/07 when service users refuse important medication. That the use of correction fluid 23/06/07 on the controlled drugs register ceases. That all medication records are 23/06/07 clear, accurate and up to date. That contaminated medicines are disposed of appropriately. That prompt action is taken to 23/06/07 ensure that service users are not at risk if medication is not taken. That service users dignity and 23/06/07 privacy is respected at all times. (timescale of 08/12/06 not met). That care plans include 23/07/07 information on how service users leisure preferences are matched by activities provided. That risk assessments are 23/07/07 carried out while internal building work is carried out. That call bells are available in 23/06/07 service users bedrooms at all times. DS0000021423.V337211.R01.S.doc Version 5.2 Page 23 Requirement 5 6 7 OP9 OP10 OP12 13 (2) 12 (4) (a) 16 (2) (mn) 13 (4) (a) (c) 16(1) 8 9 OP19 OP19 Clifden House 10 OP26 16 (2)(j)(k) 13 (5) 11 OP38 That all parts of the home are to be kept free from offensive odours. (timescale of 08/07/06 and 08/12/06 not met). That staff do not attempt to lift service users inappropriately. 23/07/07 23/06/07 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 4 Refer to Standard OP7 OP28 OP29 OP30 Good Practice Recommendations That work to bring all care plans up to date is completed without delay. That the plan to ensure 50 of staff achieves NVQ level 2 is implemented without delay. That the plan to ensure all existing staff has the required employment checks to be implemented without delay. That the plan to ensure all staff has the appropriate training is implemented. Clifden House DS0000021423.V337211.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local 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. 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