Inspection on 01/02/06 for Cliffe Vale

This inspection was carried out on 1st February 2006.

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

The inspector 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

Cliffe Vale 14/12/07

Cliffe Vale 10/01/07

Cliffe Vale 26/07/05

Cliffe Vale 26/01/05

Cliffe Vale 06/09/04

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Cliffe Vale 228 Bradford Road Shipley West Yorkshire BD18 3AN Lead Inspector Susan Knox Unannounced Inspection 1st February 2006 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 Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cliffe Vale Address 228 Bradford Road Shipley West Yorkshire BD18 3AN 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) 01274 583380 Cliffe Vale Registered Care Home Ltd Mrs Rita Christine Williams Care Home 27 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (23), of places Physical disability (1), Physical disability over 65 years of age (3) Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Cliffe Vale is located on a main bus route that goes from Shipley to Bradford. It is close to local shops. This detached property provides accommodation on ground, first and second floors. Access between floors is by stair lifts. There are three separate communal areas, including two lounge/dining rooms. Patio areas are available for service users outside. Parking is available. The majority of service users are elderly, a number may have physical and mental health needs. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 9.30am and 2.45pm the deputy manager Mrs S Robinson was on duty. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. I spoke to ten service users, three staff and the deputy manager. I also looked around the home. Records were inspected including care plans, assessments, accident reports and fire records. Feedback was given to the deputy manager at the end of the inspection. What the service does well: What has improved since the last inspection? The deputy manager has successfully completed the Registered Managers Award. The provision of activities has improved with more regular sessions including arts and crafts. Redecoration and recarpeting continues to take place and ensures the environment of the building is well maintained. Teatime menus have been reviewed in order to provide more choice for service users. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 6 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. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Service users receive documents that give sufficient details about the home to enable service users/relatives to make an informed decision about moving to the home. The pre admission assessment process is good and prospective service users visit the home. EVIDENCE: The home provides a copy of the statement of purpose/service user guide to new prospective service users and/or relatives. The deputy manager confirmed this. This was discussed with service users but due to memory loss none could recall this. The local authority provides funding for the majority of service users and issue contracts. One recently admitted service user was still waiting for Social Services to finalise the contract. Pre admission assessments are carried out and were well documented. In the service user tracked from admission the records showed that a half-day visit to Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 9 the home had been made, including dining with service users. The daily report for the date of admission showed that informative details about the service user’s needs were made known to care staff. Staff confirmed that specific training such as for those with dementia is undertaken in order for staff to meet the needs of individuals. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10 The majority of care planning ensures that individual needs are met. Service users are provided with sufficient information in order to make own choices about privacy. The majority of the service users are protected by risk assessments. There was an oversight that could have compromised the safety of one. In addition the early introduction of clinical risk assessments in care planning should be considered as a preventative tool. EVIDENCE: Three sets of care documentation were reveiwed including the case tracking of the latest admission to the home. Up to date care plans were in place and were regularly evaluated. The needs identified during the pre inspection assessment were followed through in care plans. In one case the care plan did not address nighttime needs that had occurred after admission. The deputy said these had been discussed with relatives. Advice was given about holding a review to include relatives to ensure there was no misunderstanding. It was clear that the staff had a good understanding of individual needs as queries arising from Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 11 the care plans were readily answered. For one service user the care plan addressed emotional needs related to bereavement. Daily progress reports provided good information about an admission to ensure that individual needs could be met. The deputy was aware that service user’s rights could not be compromised despite requests from relatives. One care plan clearly addressed a service user’s right to remain in bed if this was preferred. This also included that meals and medication were provided as necessary. One service user confirmed that she had a key to her room that she used. Two bedrooms have secondary fire escapes therefore cannot be locked for privacy. This information is discussed before admission and included in the contracts for these rooms. From the records and also discussions with service users and staff it was apparent that health needs were being met. Referrals had been made to a GP about depression. Nobody had tissue viability needs. The district nurses are contacted for their input where necessary. Concerns about health discussed in conversation with one service user had been addressed and the home was waiting for an appointment with a specialist. Risk assessments were in place for moving and handling and smoking. One was missing about the use of an unguarded freestanding heater in the bedroom. This was very hot to touch and could have caused injury if prolonged contact was made. The deputy was advised to safeguard the heater. Discussions were held about the use of relevant risk assessments such as Waterlow, Barthel and Nutritional. At the present time these tools are put in place following the home contacting the district nursing team. As discussed, these are useful tools and can provide an early warning about deteriorating health. If used it is important that care staff know how to interpret results. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Staff have responded to a change in the client group and provided more recreational activities. EVIDENCE: On the day of this inspection service users in both lounges were enjoying listening to appropriate music. They discussed their favourite music and confirmed that other activities took place. This was also recorded in progress notes. One confirmed that he still leaves the home independently of others to follow own interests. One showed me the knitting that she enjoyed doing. Arts and crafts had been recently introduced. One senior care takes a particular interest in activities and these are usually arranged in the afternoon. Staff said they thought the present client group had more interest and activities had improved recently. Outings happen more in the warmer months but some had gone out for a Christmas lunch. Musical entertainment is organised. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 An appropriate complaint’s procedure is in place. Service users are safeguarded from abuse. EVIDENCE: The complaint procedure is displayed in the home and is part of the documentation given to new service users and relatives. Anyone wanting to complain is provided with clear guidelines and information. The deputy said that no complaints are on going. Some senior staff have attended adult protection training, which was facilitated by Bradford Social Services. The provider/manager has given talks to staff about abuse and staff confirmed this is part of the induction into the home. Staff were familiar with the procedure for reporting concerns or any allegations of abuse. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21-24 & 26 The home is very pleasant and service users are comfortable living there. The equipment in place helps service users to remain independent. Cleanliness and good odour control help to ensure a pleasant environment for service users. Good infection control practices could be further improved in order to protect service users and staff. EVIDENCE: The majority of rooms were checked during the inspection. Bedrooms were well kept with good standards of decoration, carpeting and furniture. The majority of rooms were personalised with own belongings. Service users said they were very comfortable in their bedrooms. There is equipment in the home that helps people with independence such as bath hoists, stair lifts, handrails and wheel chairs. Staff explained that part of their duties is to check wheel chairs for cleanliness and to ensure footplates were in place. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 15 The home is pleasantly decorated and the provider has recently redecorated and re-carpeted one of the landings. Cleaning was in progress at the time of inspection. Care staff were routinely cleaning commodes and there was good odour control. Staff confirmed that they had attended Infection Control training and good practices were observed. The deputy was advised that in line with infection control guidelines no bars of soap or individual towels should be left in communal bathrooms or WC’s. These should be brought with the service users to use as required and then returned to individual bedrooms. Paper towels and dispensers are provided in communal areas but no liquid soap. This is required. Apart from the use of the freestanding radiator in one bedroom no other health and safety concerns were noted. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29. The home operates with good staffing levels. The staff team have and are working hard to achieve their NVQ awards, and have a good understanding of good care practices. The home operates with satisfactory recruitment processes in order to protect service users. EVIDENCE: A copy of the rota for the week of the inspection was provided and staffing levels were appropriate. Staff confirmed that there had been an increase in day care hours since the last inspection. The majority of care staff have attended NVQ level 2 training. Five staff have finished the award although one has left and four staff are in the process of completing it. The deputy manager has achieved the registered manager’s award. The deputy advised that the requirement to have 50 of care staff qualified to NVQ level 2 in care will be achieved by the end of March 2006. The recruitment process was checked for the last five new recruits. The process includes full documentation checks and equal opportunities. References and Criminal Record Bureau (CRB) checks including POVA first are undertaken. In two cases CRB’s were still outstanding. The deputy advised that in this case care staff work under supervision. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 17 One CRB was from another care establishment. The deputy was informed that CRB’s are non transferable. In this case employment was not taken up even though clearance had been received. The deputy was advised that the umbrella organisation should have been contacted to check if any verbal information had been disclosed. In discussing good recruitment practices the deputy was advised that when recruiting care staff, if previous employment has been in care homes then providers/managers should be contacted for references. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-33 & 38. The registered manager is qualified and competent to manage the home. Staff feel well supported. Some work has been done to check the quality of the home but a more in depth annual self-assessment would provide additional evidence about the operation of the home. Fire safety is well organised and service users are kept safe. EVIDENCE: The registered manager/provider has owned the home for many years. She has over the years attended many training courses and is an assessor. She does not intend to undertake the registered manager’s award. But the deputy has recently successfully achieved this. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 19 Staff confirmed there were clear management structures in place and they were well supported by managers. Staff meetings are held and minutes were available. Informal discussions are held with service users and it was clear that managers were in regular contact with individuals. The home has carried out self-audits with questionnaires sent to service users and relatives. The deputy was advised to consider more in depth audits and self-assessments. Fire records were reviewed and showed that staff training and safety checks were up to date. Good records of fire drills are made and include the names of staff attending. The process of inducting new staff inducted into the home also includes attending a fire drill. The records showed that fire extinguishers were checked in March 2005. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X 3 3 3 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X 3 Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Ensure that all needs are identified in care plans. Ensure that a risk assessment is carried out about the use of the freestanding radiator. Ensure that bars of soap and towels are not left in communal bathrooms and WC’s. Timescale for action 01/02/06 2 OP26 13 01/02/06 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. 2. 3 Refer to Standard OP7 OP29 OP33 Good Practice Recommendations Introduce the use relevant assessment tools as a preventative measure. CRB’s are not transferable from one employment to the next. Ensure that where previous work has been in care homes employers/managers are contacted for a reference. Ensure that more in depth audits/self assessments are carried out about the operation of the home. Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cliffe Vale DS0000048525.V279843.R01.S.doc Version 5.1 Page 23 - 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. 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