Inspection on 06/11/06 for Cliffdale

This inspection was carried out on 6th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cliffdale 23/12/09

Cliffdale 18/11/08

Cliffdale 20/11/07

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 OQD Lead Inspector Janet Oxley Key Unannounced Inspection 6th November 2006 10:00 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 Cliffdale DS0000064187.V297103.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.V297103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cliffdale Address Shrewsbury Road Pontesbury Shrewsbury Shropshire SY5 OQD 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.V297103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 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. The home is owned by Mr and Mrs Rajan Odedra and is managed on a day to day basis by Miss Lesley Passat who has the relevant qualifications and who has had many years experience caring for elderly people. The home makes their services known to prospective service users in: The Statement of Purpose, Service User Guide and web site which also contain their contact e mail address. The inspection report is mentioned in the statement of purpose and summarised in the service user guide. It is also on display in the entrance hall. Fees are reviewed annually and range from £350-£390. The only additional charges to service users are for toiletries, hairdressing and newspapers. This is clearly laid out in the terms and conditions. Cliffdale DS0000064187.V297103.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: information from the provider, looking at relevant records pertaining to key standards, discussions with residents, the staff on duty, 3 visitors and a District Nurse, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? It has to be noted that at this home, management and staff continue to review and improve all aspects of the service to achieve best practice and maintain a good quality service. A number of areas of the home have been refurbished and redecorated, all administrative systems continue to be reviewed and updated when necessary and staff training is high on the agenda. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 6 What they could do better: Shortfalls in this home, that are the responsibility of the Manager and Staff, are few. The owner must now put together a programme of maintenance and renewal of the fabric and decoration of programme should be implemented without undue delay Sufficient hours should be given each week to maintenance temperatures must be regulated satisfactorily. necessary routine the premises. This with records kept. work and hot water To enable the manager to undertake all her management responsibilities she should be given additional supernumerary hours. 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. Cliffdale DS0000064187.V297103.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 Cliffdale DS0000064187.V297103.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): Standard 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which include all the required information for prospective residents. Documentation examined indicated that individuals have a full and comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Discussions with residents, a senior carer and staff on duty and observations indicated that the home continues to meet the individual needs of the elderly people living at the home in a professional and sensitive manner. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are very well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 11 EVIDENCE: Personal and healthcare support in this home is offered in such a way as to promote and protect service users’ dignity and privacy in their daily life and at the end of life. It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff, 3 visitors, a District Nurse and residents that individual health, personal and social care needs were being met. Care planning system is currently being reviewed and developed and personal care monitoring is undertaken by senior staff to ensure that staff are following the care plans and that the residents are all getting a good quality of care. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives at the home and visiting health professionals praise the management and care standards there. Those residents being looked after in bed looked extremely comfortable and well cared for Medication appears to be stored, recorded and administered satisfactorily and relevant staff have received the necessary training. The Home is soon to change to a Monitored Dosage System and will then be working on reviewing and amending the policy documents and staff training. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 12 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): All standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Cliffdale are very flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many activities take place, there is an open visiting policy and the menu offers a choice of well balanced and wholesome meals. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 13 EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms and use them as private places. A number of activities are arranged within the home and outside. These activities are regularly made known to all residents and their families. Individual needs, likes and dislikes are clearly shown in the care plans. Menus, the meal seen and tasted and discussions indicated that an excellent diet was on offer and that the catering arrangements were satisfactory. The cook is familiar with the residents requirements and preferences. Staff were seen to support the more frail residents to eat their meal in a sensitive and professional manner and the dining areas are pleasant with attractively laid tables. Residents are certainly enabled to exercise choice and control over their own lives as far as they are able and those spoken to were very complimentary regarding all aspects of their lives at the home. There is a good range of information for residents and visitors within the home including aspects of advocacy and legal and financial matters. Visitors are always made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors spoken to have been complimentary regarding the care the residents receive at the home and the 3 spoken to at the time of this inspection offered no concerns or complaints, just compliments. The home is very much a part of all aspects of the local community. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff are provided with induction and on-going training regarding adult protection. This provides staff with the relevant knowledge to safeguard service users from many types of abuse. EVIDENCE: The home has a complaints procedure, which is referred to for information in the Service User Guide. There is also a protocol in place that enables residents to contact the proprietor if at any time they are not satisfied with responses received from the manager about a complaint. There is a system of recording complaints but no complaints have been made. There have been no complaints directed to the Commission for Social Care Inspection since the last inspection. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 15 Residents reported that they knew what to do to make a complaint however had not found it necessary as the staff were all helpful, kind and would do anything they asked and reviews are always undertaken with the residents and relatives inputs. All necessary policies and procedures are in place in relation to the protection of vulnerable adults. The manager had completed the vulnerable adults training provided by Shropshire County Council and all staff have received relevant training on the subject in induction and foundation training. The home also has a policy concerning residents’ money and financial affairs. Residents either manage their own financial affairs or rely on family members for support. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 23 and 26. Quality in this outcome area is adequate. The standard of the environment within the home provides residents with a warm, safe and homely place to live however it was identified and fully acknowledged that a number of improvements need to be made without undue delay. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Bedrooms are personalised and suit individual needs and the gardens and grounds are generally well maintained and accessible to residents and their visitors. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 17 At the time of the most recent Fire Officer and Environmental Health Officer’s inspections matters were reported to be satisfactory and any recommendations made have been complied with. It was identified that a number of areas of the home will need refurbishment, repair and redecoration in the near future and a full programme and plan for routine maintenance and renewal of the fabric and redecoration of the premises will be forwarded to CSCI without undue delay and this must be implemented within timescales agreed. There was evidence to suggest that additional maintenance hours are required. At the time of this inspection the standard of hygiene and cleanliness was generally satisfactory and staff have received training in infection control. Laundry facilities will need to be improved to provide floor and wall finishes that are impermeable and so readily cleanable. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 18 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): All standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users appear to be supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: The rotas, ratios of staff on duty at the time of inspection and the number of domestic, laundry and kitchen staff indicated that the home meets the laid necessary staff compliment. It was considered however that the home would benefit from additional maintenance hours and that the manager should have more supernumerary hours in which to undertake her management responsibilities and the required administrative duties. Recruitment at the home appears thorough and all elements required by Schedule 2 of the Care Home Regulations are maintained on file. The files of 2 newly recruited staff were seen to be satisfactory and staff members were very complimentary regarding the induction, support and supervision they had received. Staff turnover is fairly low and agency staff are rarely used. The arrangements for ongoing training and foundation training are satisfactory with staff completing this well within the first six months. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 19 The home continues to support staff to undertake their NVQ awards, more than 50 of care staff have achieved NVQ level 2, a good variety of other training has been undertaken and staff on duty indicated that they were very sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the manager and senior staff. Recorded staff supervision, staff meetings and appraisals are undertaken and staff confirmed that this was so during discussions and all spoken to were complimentary regarding the management and care at the home. Training records are maintained for each staff member. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home reviews all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is fully qualified and has many years experience. It is evident that she continues to update her own professional knowledge by attending a number of related courses to the resident group catered for. At the time of this inspection the Manager and her Deputy were attending training with Shropshire Partners in Care. The manager involves herself fully in the day-to-day running of the home and can relate to matters pertaining to the National Minimum Standards. There was evidence on the duty rota however that she has to cover for care staff and is expected to undertake shifts on the floor each week. It was considered that this was not wholly satisfactory and that she requires additional supernumerary time in which to undertake her managerial duties. The manner in which the Senior carer and staff on duty responded to this inspection indicated that a sound management approach is in place and that staff are committed to achieving best practice and to developing equal opportunities. Equality and diversity for the service users were seen to be promoted throughout the home, within the assessments, care plans and activities. Equality for staff is promoted through opportunities for training at all levels. Quality assurance systems are in place and there was evidence available to indicate the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. All staff have attended health and safety training and relevant mandatory training was reported to be up to date or booked for the near future. At the time of this inspection one hazard was identified and that was the water to one bath on the first floor exceeded 43oc. This rectification of this matter was reported to be in hand. All records required are maintained. The accident records appeared to be satisfactory and it was reported that a first aider is on site at all times. Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 22 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x 3 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 x x 3 x x 3 Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23(2) Requirement That a programme and plan of routine maintenance and renewal of the fabric and decoration of the premises be produced and be implemented within stated timescales and records kept. That laundry floor and walls be made permeable and are readily cleanable. That to prevent the risk of scalding all baths must have fail safe devices so water does not exceed 43oc Timescale for action 31/12/06 2 3 OP19 OP38 23(2) 13(3) 31/12/06 30/11/06 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 OP31 Good Practice Recommendations That the manager have additional supernumerary hours each week to undertake her management responsibilities and administrative tasks. DS0000064187.V297103.R01.S.doc Version 5.2 Page 24 Cliffdale Cliffdale DS0000064187.V297103.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 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.V297103.R01.S.doc Version 5.2 Page 26 - 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!