Inspection on 26/07/05 for Cliffe Vale

This inspection was carried out on 26th July 2005.

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 01/02/06

Cliffe Vale 26/01/05

Cliffe Vale 06/09/04

Similar services:

Snydale Care Home

Abbey The

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 Announced 26 July 2005 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 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 J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cliffe Vale Address 228 Bradford Road, Shipley, West Yorkshire BD18 3AN Telephone number Fax number Email 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 01274 583380 Cliffe Vale Registered Care Home Ltd Mrs Rita Christine Williams Care home only 27 Category(ies) of Old age (23), Dementia - over 65 (6), Physical registration, with number disability (1), Physical disability - over 65 (3) of places Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26 January 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 J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspection officer carried out this announced inspection. It started at 9.30 am and finished at 4 pm. The inspector dined with service users for the main meal of the day. The provider completed pre inspection forms in time for the inspection. Comment cards were distributed to service users and relatives and a number were returned. Time was spent talking to service users, staff and observing care practices. Records were checked including duty rotas, care records, recruitment records and staff training records. Some bedrooms and other areas were checked. Feedback was given on the findings to Mrs Williams provider/manager and Mrs Robinson deputy. What the service does well: What has improved since the last inspection? The numbers of care staff undertaking NVQ level training has improved. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 standard(s) 3, 5 Information is available about the home so that informed decisions can be made before moving in. Service users and relatives are given an opportunity to visit and/or stay before deciding whether to move in. EVIDENCE: All residents are assessed before admission to the home to make sure that their needs can be met. Pre-admission assessments provide detailed information about the individual’s needs. Information about the home is freely available in the main entrance. Service users confirmed that relatives looked around the home before admission, as they were unable. Care documentation also confirmed that in one instance a prospective service user had a half-day visit to the home. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11. Care planning is good, well documented and up to date. Health care needs are met. Residents are treated with respect and their privacy maintained. Terminal care provision is good. Arrangements after death should be discussed if appropriate with service users and relatives. EVIDENCE: Four-service user’s care records were looked at. The care planning addressed individual needs. Monthly evaluation takes place ensuring that any changes are identified and appropriate action taken. Care planning was well documented and up to date. Recognised assessment tools are in use and risk assessments were in place. Some additional information was required as recommended in feed back. The home operates with a monitored dosage system (MDS). Records and storage of medication was checked and found to be satisfactory. Medication is checked into the home that is not part of the MDS, as required. Records are kept for medication returned to the pharmacist for disposal. The pharmacist checks the system periodically. There is a list of staff names responsible for Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 10 administering medication. This should include a specimen record of each person’s initials. The procedures carried out in cases of terminal care were discussed with staff. From this and from records it was clear that a high standard of care is provided at these times. The manager and staff would consult with relevant agencies for help and advice. The care plans need to reflect this by establishing a plan for pain relief and a record of the service user’s last wishes. As discussed it is acknowledged that last wishes are a difficult subject to talk about. This can be dealt with in most cases, along with other forms shortly after admission. Some staff have recently attended training related to Palliative Care. From discussions with service users and from the comment cards it was clear that the majority feel that staff respect service user’s privacy. This was also confirmed from observations during the visit. The majority of the comment cards returned by relatives said they were satisfied with the overall care provided. One stated ‘the staff really care and are always friendly and cheerful’. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15. Service users are provided with choice and the opportunity to act independently. Relatives are welcomed by staff when visiting. Service users enjoy the food provided in the home. A review of teatime meals will ensure a good choice of meals is provided throughout the day. EVIDENCE: A small number of service users are able to leave the home independently of others. Arrangements for organising this was observed on the day of the visit. It was apparent that choice is provided, as some were finishing breakfast after choosing to stay in bed late. The comment cards returned from relatives all confirmed that service users can be visited in private and that staff welcome visitors to the home. The inspector took the main meal of the day with service users. The meal was tasty, presented well and enjoyed by others in the dining room. It was leisurely and many were asked and accepted second helpings. Staff actively encouraged fluids to be taken and also those forgetting to eat. Staff displayed an in depth understanding of service user’s needs at meal times. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 12 Three weekly menus are available. These showed that a varied nutritional diet is available. Teatime menus were discussed as having limited alternatives on some days with savouries on toast or sandwiches being available. There are a higher number of service users with short-term memories in the home at the present time. The provision of dining tables in the two lounges in addition to the dining room helps to overcome the problems that can be created by a diverse mix of service users. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 standard(s) 16, 18. Complaints are listened to and dealt with according to the home’s complaint procedure. Staff have received training in adult protection and there are comprehensive policies about abuse. EVIDENCE: There is a detailed complaints procedure and a record is maintained of all complaints received including details of the investigation and the outcome. The manager advised that no complaints have been received since the last inspection. During discussions with service users it was clear that they would approach staff with any concerns. The provider has ensured that staff are familiar with adult protection policies and procedures. In house training has been held for all staff. Four staff have attended the local authority adult protection course. The deputy manager has also completed an adult awareness level one course. During discussions with staff they had a good understanding about the issues of elder abuse and confirmed that in house talks had been organised. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 24, 25, 26. The home provides comfortable accommodation in a building that is that is well maintained. Service user’s bedrooms are personalised and comfortably furnished. The home is clean with good odour control. EVIDENCE: The garden is well kept and provides a pleasant area for service users to enjoy good weather. Staff confirmed that service users are taken out into the garden in order to enjoy the fresh air. The providers strive hard to ensure that decoration and furniture is well maintained. New carpets have been laid in four bedrooms and three new beds and bedding purchased. One bedroom, bathrooms and toilets have been redecorated. A number of rooms and areas were randomly checked. The home is well decorated, with good standards of cleanliness and odour control. Many service Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 15 users had their own possessions displayed and rooms were homely and inviting. Service users said they were comfortable in their rooms. No health and safety concerns were noted Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 Staffing levels are sufficient to meet service users’ needs. The providers have increased staffing levels in order to meet service user’s needs. Recruitment procedures make sure that staff are suitable before they start work in the home. The home has a training programme to make sure that staff receive the training required in order to meet the needs of service users. EVIDENCE: Duty rotas were made available before the inspection. These showed that staffing levels were appropriate. A few comment cards from relatives expressed a concern about levels of staffing. However this was not identified as a problem during the inspection. Staff said that although sometimes in the day things can get hectic they can cope and morale was good. The providers had already recognised that certain times of the day were busier than others. In order to overcome this, an extra domestic had been recruited to take some duties from care staff and ten more care hours have been introduced. NVQ level 2 training is well underway for nine care staff. The deputy has completed NVQ level 4 and the Registered Manager’s Award and is awaiting feedback from submission of final work. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 17 Recruitment practices were good. Staff files were well kept with evidence of CRB checks and references obtained before employment began. Job descriptions and terms and conditions were available. Staff training is on going with the providers committed to the provision of adequately trained staff. This was clear from discussions with staff and managers and evidenced in training records. Further training has been planned that will cover Moving and Handling, Dementia and Falls Prevention. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34-38 The interests of service users are protected. The health and safety of service users and staff is promoted and protected. EVIDENCE: An up to date public liability certificate is displayed in the home as required. The providers have confirmed that insurance of the building and business is sufficient. The providers have confirmed that they are not involved in service user’s finance. Records and receipts were seen for personal allowances kept on behalf of individuals. Staff receive supervision and these records were seen. This was also confirmed in discussions with staff. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 19 In the pre inspection questionnaire the providers confirmed that health and safety maintenance and checks were up to date and in accordance with recommendations. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x 3 3 3 3 3 Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? 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 11 Regulation 12 Requirement Discuss arrangements for terminal care and after death were possible with service users and/or death. Timescale for action 15 september 2005 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. Refer to Standard 9 13 Good Practice Recommendations Ensure that specimen initials are kept of staff admisitering medication. review the alternatives provided for tea time meals. Cliffe Vale J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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 J52 S48525 Cliffe Vale V231780 260705 Stage 4.doc Version 1.30 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. 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!