Inspection on 20/11/07 for Cliffdale

This inspection was carried out on 20th November 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

Cliffdale 23/12/09

Cliffdale 18/11/08

Cliffdale 06/11/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cliffdale Shrewsbury Road Pontesbury Shrewsbury Shropshire SY5 0QD Lead Inspector Pat Scott Draft Key Unannounced Inspection 20th November 2007 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 Cliffdale DS0000064187.V347333.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. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cliffdale Address Shrewsbury Road Pontesbury Shrewsbury Shropshire SY5 0QD 01743790261 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) Rajan Odedra Usha Odedra Miss Lesley Passant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Cliffdale is a private care home registered to provide care and accommodation for up to 27 older people. It is situated in the village of Pontesbury, some 8 miles south west of Shrewsbury, within easy reach of all local amenities and set in pleasant gardens. Accommodation is available on first and second floors accessed by a shaft lift. Fees are reviewed annually and range from £365-£380. This information applied at the time of inspection and people may wish to obtain more up to date information from the care home. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the area manager, tour of the premises, previous inspection reports, quality assurance processes, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? What they could do better: The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It did not give us all the information we asked for. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 6 There was a lack of information in the AQAA about the areas that the service felt that it had or could improve or how it had met previous recommendations and requirements made by the CSCI. The service information content and availability should improve i.e to make the statement of purpose more reader friendly and visible in the home. Assessment records for new admissions need to be consistently completed and more organised. Through service audits, gaps should be identified and action plans provided to address shortfalls in documentation. Care plans could be completed in a more person centred way providing staff with clear directions for individual care. Implementation of the new format and consistent use of this will give a more informed indication of care provided and progress made by individual service users. Serious consideration should be given to staff being involved in planning and recording of the personal care they provide to service users. Bed rail risk assessments could be more robust so that the conclusions reached to use them are clearly documented. Service users should be offered a choice of meal from a menu that includes a healthy option. Improvements for managing foul linen were promptly actioned by the area manager during the inspection. Red alginate bags are on order for staff to deal with foul linen at source. The health and safety of service users and staff would be better protected by the installation of a sluice disinfector, given the use of some commodes and not all rooms having en-suite toilets. This would reduce the risk of cross contamination associated with disinfecting by hand. The laundry should have a sink dedicated for hand-washing. There is a lack of evidence of robust service monitoring by the management. The manager should be consistent with audit systems and quality reviews of the service i.e. medication, care plans, surveys/results. This would ensure that the service is checking that practice meets polices and procedures and that service users’ health and personal care matters are consistently addressed. The service could review the use of the reception area to make it a more welcoming space for visitors. Please contact the provider for advice of actions taken in response to this Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 7 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. Cliffdale DS0000064187.V347333.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 Cliffdale DS0000064187.V347333.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): Key Standard 3. National Minimum Standard 1 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are not provided with the information needed for them to choose a home which will meet their needs. Omissions of records for the admission of new people to the service do not demonstrate that the process is personalised or that consideration has been given to all aspects of care. EVIDENCE: The admission records of 3 new service users were viewed, including one who had been admitted in an emergency from home. Two take into account the individual needs of the service user including a risk element. These were in standard format with little extra consideration of individual requirements. The file of another service user admitted in an emergency had no assessment details pre or post admission although staff could give a verbal account of the process. The service does not have a policy or procedure to admit service Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 10 users in an emergency. The statement of purpose does not indicate that admitting people in an emergency is a stated intention of the service. The service holds copies of the summary, and care plans, from those assessments carried out through care management arrangement process. Staff receive training to ensure that they have the necessary skills and ability to care for residents who are admitted. The provider has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service. The information is not visible in the home. Cliffdale DS0000064187.V347333.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): Key Standards 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of detail of service users’ care needs in their individual plans of care does not demonstrate that all care needs have been addressed and will be fully met. The service understands the need to comply with safe medication systems and has introduced the monitored dosage system. Lack of medication audits does not ensure that the home’s procedures are complied with and that service users health matters are always safely addressed. The actions of staff and their approach to care ensures that service users are treated with respect and their right to privacy is upheld. EVIDENCE: Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 12 The care plans were viewed of two of the three new service users. The third could not be located. The plans detail basic information and provide little direction to staff on how they are to deliver care. The recording is not written in a way that demonstrates personal preferences and wishes are taken into account, although staff can provide a verbal account of this, and service users stated they do. A new printed format is in place in files but have not been completed for two new service users. Bed rail risk assessments are in place but do not demonstrate how the conclusion to use rails has been reached. A bed rail daily check-list is in the service users’ bedroom, one of which was last signed 3/11/07. Nutritional risk assessments are conducted and one service user deemed at low risk with a score of ‘0’ had a care plan stating ‘may need help from staff. Food supplement.’ There was no indication what this supplement was or any other directions for staff. There is recorded evidence of updating information and changing actions in the daily records. Service users have access to health care services that meet their assessed needs both within the home and in the local community. Service users have access to dentists, opticians and other community services. The service users’ health is monitored and appropriate action taken. The home seeks professional advice on health care issues, acts upon it and generally is able to provide the aids and equipment recommended. Risk assessments documented show that safety issues are addressed whilst not impinging too much on the freedom of the individual to take risk. A service user commented “ residents are treated with dignity and patience by caring staff.” The home has a medication policy which is accessible to staff. Medication records are up to date for each service user and medicines received, administered and disposed of are recorded, with the exception of two signatures for hand transcribed medication. One service user who is self medicating, does not have a record of receipt for her drugs or a medication chart. The medication storage room is quite warm and the service agreed to monitor this and take appropriate action. Staff were seen to be aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for service users to enjoy the privacy of their own rooms and provides screens in shared rooms. Service users spoken to stated they were happy with the way that most staff deliver their care and respect their dignity. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 13 Other comments include: ‘they look after me very well’, ‘staff are very kind and caring’, ‘pleased to have mother in such a nice home’. Service users all appear well groomed with their hair, nails and clothes looking clean. Some stated that they have clean clothes daily. No issues were identified in discussions regarding approach of staff or being assisted with intimate tasks. Cliffdale DS0000064187.V347333.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): Key Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with social activity and can keep in contact with family and friends. Social, cultural and recreational activities meet service users’ expectations through choice. Service users receive a nutritious diet but are not enabled to exercise choice. EVIDENCE: Social activities are provided through informal discussion with people as to what they would like to participate in. A service user pointed out the activities described on the door. These include; communion, story telling, sherry and mince pie afternoon, newsletter, extend class. Menus are not seen by service users and those spoken with did not know the lunch for the day. Some were happy with this, and others stated they would like to know ‘what is on offer’. Staff state that they know the service users likes and dislikes, but, as one service user pointed out, ‘preference may change over time and meals are something to look forward to’. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 15 Visitors were seen to come and go and had very positive comments to make about the care in the home and how their relatives spend their time. Cliffdale DS0000064187.V347333.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): Key Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure so that people who use the service can make complaints about the home. Training is provided so that service users are protected from abuse and have their legal rights protected. EVIDENCE: One instance is being addressed through the multi-agency safeguarding process. Staff have monitored the situation well and sought advice through the correct channels. Staff have received adult protection training. Service users spoken to say that they would go to the manager, or one of the staff if they had a problem. One person said that they would speak to the senior carer, as they’ve known her a long time. All expressed confidence that issues will be dealt with. Concerns spoken about by service users had been promptly dealt with and a satisfied outcome reached. The service does not have an audit process for monitoring complaints and identifying trends in any failings. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe and comfortable environment, which encourages independence. EVIDENCE: There are plans to redecorate and re-carpet some areas of the home with some already having been done. Generally areas seen around the home are clean and rooms personalised. Call bell systems are working and are within reach of service users. The garden is not accessible for all service users but the area manager reported that plans are in place to address this. The ‘reception room’ on entering the premises is where staff conduct handover. Policies and procedures are on display to be read by staff. However, Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 18 other documents such as complaint log sheets, diary, accident book etc were also in the room which could be open to public view. A ceramic slop hopper is reported to be used to hand sluice dirty linen in the laundry. This is not good infection control practice and dirty linen should be handled at source. There is no sluice facility for disinfecting commode pots and other utensils. There are two large ceramic sinks in the laundry area with neither of them dedicated for hand washing only. However, soap and towels are available. The laundry floor has been improved so that it is now washable. Environmental Health Officers have conducted an inspection of the kitchen facilities and matters arising are being addressed. It is the intention of the service to modernise and upgrade kitchen facilities in the future. The area manager stated, after consultation with the provider, that the requirement regarding fitting thermostatic valves to all hot water outlets, will be in place by the end of December 2007. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of thorough recruitment steps does not ensure the service secures suitability of candidates before working in the home and service users may not be in safe hands. Staff in the home are being trained and are in sufficient numbers to fill the aims of the home and meet the changing needs of service users. EVIDENCE: The manager stated that the common induction standards booklets are being used for two new starters. The area manager stated that recruitment is in hand to increase staff numbers. The recruitment process is not robust. Two had started with no statement on file to show that the full criminal record check and POVA 1st check had been returned. One overseas candidate did not have any required documentation on file. The start date of individuals could not be identified on their files. A staff training matrix shows training planned but without specific dates to indicate that attended. Mandatory training is provided and specific topics such Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 20 as; dementia, parkinsons disease and nutrition are planned. Staff do not have individual training profiles but certificates are reported to be photocopied and kept on the recruitment file. Service users spoken with stated they are well cared for and that staff are very helpful. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, but without effective quality assurance systems and audits in place, service users are not assured that the overall conduct of the home is being well managed. EVIDENCE: The registered manager was not on duty during this inspection. There was a lack of information in the service’s quality assessment (AQAA) to indicate that formal audits are conducted to check whether policies and Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 22 procedures are being adhered to and that systems are working to achieve good outcomes for service users. No information could be identified at the inspection to confirm that quality assurance takes place within the service other than the day to day informal interaction with service users. The AQAA stated that there had been a response to surveys re odour management, with no further information as to other areas of service surveyed. Checks on records show that they are generally up to date although gaps were found in recording and entries were not always clear, e.g. care plans, assessments, recruitment files, bed rail checks. New care plans for the service had not been fully implemented. A supervision process is in place but it is not up to date with supervision sessions outstanding from September 2007. Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 23 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 2 X 2 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 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 24 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 Standard OP29 Regulation 19(1) Requirement The manager must not confirm new employees in post before all recruitment checks have been completed. This ensures that service users are supported and protected by the home’s recruitment policy and practice. The registered manager must ensure that risk assessments are carried out for the use of bed rails and that the findings of the risk assessment are recorded. This must be done so that the health, safety and welfare of people who use the service are promoted and protected. The risk of scalding from hot water must be reduced. Hot water outlets must have fail-safe devices so water does not exceed 43degrees Celsius. Timescale for action 21/11/07 2 OP38 13(1)(c) 21/11/07 3 OP38 13(3) 31/12/07 Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 25 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 OP1 Good Practice Recommendations The service should update the statement of purpose and service user guide so that prospective service users have the information they need to make an informed choice about where to live. The recording of entries within admission assessments should improve and be completed in full demonstrating consultation with all parties concerned. The recording of entries within care plans should improve so that they give clear direction for staff on how to deliver individual care. The recording of entries within medication records should improve to ensure that practice complies with policies and procedures and guidance. The service should devise menus that can be viewed by service users. Service users should be able to make a choice from the options on the daily menu. The provider should consider installing a thermostatic sluice disinfector and remove the old ceramic sluice. A dedicated hand wash facility should be identified. The manager should be consistent with audit systems and quality processes of the service. 2 3 4 5 6 7 OP3 OP7 OP9 OP15 OP26 OP33 Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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 Cliffdale DS0000064187.V347333.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!