Inspection on 19/09/06 for Clifford House

This inspection was carried out on 19th September 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clifford House 16/12/08

Clifford House 20/08/07

Clifford House 07/10/05

Clifford House 17/06/05

Clifford House 25/01/05

Clifford House 26/07/04

Clifford House 09/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Clifford House Lucy Street Blaydon Gateshead Tyne & Wear NE21 5PU Lead Inspector Mr Steve Tuck Key Unannounced Inspection 19 , 27 September and 14 November 2006 08:30 th th th Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 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 Clifford House DS0000007373.V309215.R02.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 Adults 18-65. 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. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifford House Address Lucy Street Blaydon Gateshead Tyne & Wear NE21 5PU 0191 414 8178 0191 414 8959 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) Clifford House Homes Limited Mrs Patricia Sowerby Care Home 10 Category(ies) of Learning disability (10), Physical disability over registration, with number 65 years of age (6), Sensory impairment (1) of places Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Clifford House is a large two storey building converted into two large flats. Five people live in each flat. The home provides care for people who have a learning and / or physical disability, some of whom are over 65 but cannot provide for people who need nursing care. The home is situated in the Blaydon area of Gateshead and is close to a variety of local shops and other facilities and is near to transport routes, which give good access to Newcastle and Gateshead. The home also has its own transport which can be used by service users. Each flat has separate facilities including kitchen, dining and sitting areas. All service users share other parts of the building such as the laundry, gardens and patio areas. The design, layout and facilities provided in the downstairs flat are suitable for those people who have a physical disability. All necessary facilities are provided including an emergency call system and a lift that takes people to and from the first floor. It costs from £671.61 to £817.44 each week to live at this home. Additional charges are made for toiletries, newspapers / magazines, and hairdressing. Items, which are included in the cost, are listed in the homes terms and conditions. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and was planned in advance. The manager or the staff at the home were not told before the inspection. The inspector spent time talking to a number of the people who live in the home as well as the manager and staff. He watched the way that care staff carried out their work and joined two service users for lunch. Some of the records that staff and the manager use were looked at including care plans and staff duty rotas. The inspector looked around the house, which included all areas that people use together and some service users’ bedrooms. What the service does well: The staff and manager have worked together with service users to make sure that the home can meet the needs of the people who live there. These are written in care plans, which show how service users needs will be met. They have welcomed new people to the home, helped them to settle in and know what staff have to do to support them. Staff help people to have interesting lives, they help make sure that people can take part in activities they like and they help them to find and try new ones. People living or working at the home get on well together, they looked comfortable and happy, talking about their day and giving their views. There is a good atmosphere at the home where service users and staff get on well with each other. One person said, “I like it here the staff are alright and they take me out”. The manager and staff work well as a team and they talk to each other so that everyone knows how to support people. Almost two thirds of the staff have been trained and some are taking more training to find out about new ideas and to get better at helping people. The house is comfortable and is decorated and cleaned to make it a pleasant place to live. Service users rooms are private; they can have their own keys and make rooms their own with furniture and possessions if they want to. The house has been changed so that it is easier for people to get around or use the facilities. The home has gardens which people use when the weather is good. There is a choice of meals offered, chosen by service users and the food is fresh and of a good quality. And people living at the home said that they like the food. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 and 4 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of information about what life is like at the home is available to help people to decide if they want to move there. Each service user’s needs are assessed before they move to the home. This helps to make sure that their needs can be met at the home and inappropriate admissions are avoided. EVIDENCE: The home has a written information called the service users guide which gives all of the important things that people need to know about the home such as how to make a complaint and the most recent Inspection report. This helps people to get an idea of what it is like to live at the home. The manager prefers people to visit the home before they decide to move in, for example by offering visits and overnight stays. Each service user’s needs are assessed before they move to the home either by a social worker from the council or the manager, or both. This is so that the manager can be sure that the home is the right place to meet the needs of people who are going to live there. The manager also finds out the cultural and lifestyle needs of people who wish to move to the home to make sure that these can be met. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 9 One person has successfully moved to the home since the last inspection and records show that the introduction to the home had been carefully considered by social workers and supported by staff and the manager. The home is able to meet the needs of everyone who is living there at present. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Each person who lives at the home has a care plan, which sets out their preferences and needs and how they will be supported by staff. This helps to make sure that staffs’ care practice is good. Service users are helped and advised to make choices and decisions about their lives and take calculated risks so that they can live as independently as they can. EVIDENCE: Everyone who lives at the home has a care plan. These have lots of details in them which tells staff how to support the physical, emotional and lifestyle needs of service users. Care plans are updated by staff every month, overseen by the manager and reviewed every six months or sooner if peoples needs have changed. Where possible service users are involved in making and keeping care plans and staff help service users to make choices about how they live their lives. Typical choices that people have made are about what they do in the daytime or the interests that they have. Most staff have had Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 11 training about how to write and maintain care plans which they have successfully put into practice at the home. Service users are treated with respect by staff at the home. Relationships between service users and with staff are relaxed, friendly and informal which helps people to feel comfortable. Staff and the manager at the home help service users to take measured risks, for example to do something on their own or with less help from staff. Some people are being supported to go out from the home or spending time around the house without staff. Staff have agreed the actions that they take to make sure that people are safe and these are written in care plans so that everyone can follow them. People living at this home give staff and the manager their views about the service and they are respected by staff. For example by following their wishes when they go into bedrooms or private areas. Staff also listen to service users views and are courteous and respectful of their views. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assisted by staff to have active and interesting lives by finding and getting to different opportunities in the local and wider community. This helps them to lead a full and enjoyable life. People who live at the home are respected, and routines are flexible. This can help to promote service users’ choices and preferences. Service users are supported to keep in contact with their relatives and friends and are able to spend time together outside of the home. The food is of good quality and sufficient to meet the needs of service users. This helps them to enjoy meals and stay healthy. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 13 EVIDENCE: Some service users have active lifestyles and their own routines and activities many of which take place outside of the home with the support of staff, friends or other agencies. While the needs of some service users living at the home have increased because they have become older or they are suffering from poor health, staff have carefully considered how to support them so that they have interesting lives. Service users have the opportunity to use the ‘Links in Gateshead’ befriending scheme run by the local authority and can find employment opportunities and can get support if this is what they wish to do. Other people have taken college courses where they have an interest or skill. The home has a vehicle, which helps service users to get out and about, and the home is next to the main bus routes, which gives good access to Gateshead and Newcastle. Staff are helpful and use their knowledge of the local area to find out about activities which are taking place and had making sure that support and transport is available for those people who want to take part. One person said “I’m getting ready to go out today and the staff will help me to get around.” Staff help service users to keep in touch with friends and relatives by making phone calls writing cards or letters or by encouraging people to meet and spend time together. Some people have been on a weekend holiday break where they paid for their own expenses. This was enjoyed by everyone who took part. Several choices of meals are offered at all times and service users help to plan their meals. Attempts to offer a balanced diet whilst still responding to service user choices were noted. Some people need to eat food which helps them to stay healthy for example if they have a medical condition. For these service users special diets and food supplements are made available and staff help by helping them to check their weight. Staff join service users at mealtimes to offer support and assistance where needed. Mealtimes are pleasant sociable events at the home where people talk and enjoy each other’s company. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health care needs are identified and arrangements are made to help make sure they are promoted and met. Staff and the manager also make sure that each service user has access to the health care services and treatment they need. The way that staff at the home helps service users to take their medication helps to that people get the treatment which they have been prescribed and mistakes are avoided. EVIDENCE: There are detailed records of service users healthcare needs in care plans which show that these are supported by staff who look out for possible illnesses. For example if a service user has delicate skin, ways of working are agreed amongst all staff so that treatment takes place and then continue to be monitored. All service users have a General Practitioner who can also refer to other health care professionals when this is required. The manager takes action to make sure that service users can get the healthcare treatment which they need and Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 15 make sure that service users can make informed choices about how their health. One GP has complimented the staff and manager about their good practices in making sure that healthcare needs of service users are carefully monitored. Staff have carried out some thoughtful work where they have needed to meet the healthcare needs of service users who do not use language to communicate. Any personal care or discussion is carried out in private with staff encouraging service users to be discrete where this is required. Due to their levels of need, service users are not able to administer their own medicines, and designated staff therefore assist in this area. Staff at the home have taken training about how to store record and give out medication. Medication is locked away and records are accurate which makes checking simpler and avoids mistakes. Some people don’t have medication all the time so staff write down rules about when medication should be given so that these can be followed by everyone. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their families can make a complaint if they are unhappy, have a grievance or dispute. They can also give feedback when they are happy with the service. This helps them to have control over their lives and shows that their views are valued. The home has measures in place which protect service users from being harmed which helps to promote their safety and security. EVIDENCE: There is a clear complaints procedure in place at the home which tells people how to complain and the length of time a response will take. On a day-to-day basis the manager and staff make sure that service users are asked for their views and they are supported to make choices and decisions. Whilst there have been no instances where abuse has been suspected or reported, the home has an adult protection procedure which is robust and complies with the Public Disclosure Act and the Department of Health Guidance. Information about the role of the local authority is available and included in the homes procedures. There is a staff guide which gives clear instructions about the actions which they must take if abuse is disclosed or witnessed. All staff spoken to are knowledgeable of these practices and have had training. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with a homely, clean, comfortable environment, which promotes their privacy and independence. Aids and adaptations have been provided to promote service users’ independence and safety. EVIDENCE: The home has had recent repairs, there is ongoing maintenance and a plan for redecoration and renewal is in place. The home is kept clean by staff who take effective steps make sure that the home does not have any unpleasant smells. Service users are encouraged to keep their own rooms clean and tidy and they are helped by staff when this is needed. The home has two floors where each with a separate kitchen lounge and dining area. All areas of the home have been adapted so that service users can have safe access to the house and gardens without restricting the rights, freedoms Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 18 or independence. And service users are able to lock their bedroom doors so that they can have privacy. The bedrooms are pleasant areas, which have a range of furniture, and fittings which are comfortable and useful for service users. All service users have decorated their rooms with their items, photographs and keepsake’s. There are enough toilet and bathrooms available, some of which have been changed to help people who have mobility needs to use them. Other changes have been made around the home when this has been suggested by occupational therapists. All service users have areas where they can talk to other people or visitors in private. The staff have agreed ways of working in the laundry which lessens the chance of infection or diseases being passed between people living or working at the home. The home is also inspected by the Fire Prevention Service and overseen the local authority to make sure that risks from an accidental fire are lessened and a safe and healthy environment is promoted for service users and staff. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 and 36 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient staff available to meet the needs of people living at the home at the moment. This helps service users to have their personal and healthcare needs met and also to get the support they need to have an active life if they wish. Staff have also been appointed without checks to make sure that they are suitable to work with vulnerable people therefore placing service users at risk. EVIDENCE: Few staff leave the home so they have longstanding relationships with service users and they are knowledgeable of their personal histories and needs. When staff and service users meet, they get on well together have positive relationships and clearly enjoy each other’s company. Staff are able to describe the needs of service users, both in terms of their practice and the principles which underpin the service that they give. 65 of the staff team have now attained NVQ awards in care at level 2 and a number are taking level 3 courses. There is a training programme at the home but neither of the two new staff had received Induction training. The manager said that she was finding it harder to find training courses that staff need. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 20 Two staff had been appointed without having a Criminal Records Bureau or POVA First check carried out prior to working with service users at the home. All staff at the home receive regular day-to-day support from the manager to ensure that service users needs are met. One to one supervision covering their care practice and training needs has not taken place. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 41 42 and 43 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The manager offers leadership and direction to the staff so that they can meet the needs of service users. The home has all of the policies and procedures required, which help staff and the manager run the home efficiently and for the benefit of service users. The financial viability of the home has not been demonstrated which would give assurance to service users and their families that the home will remain open. Arrangements to make sure that the health safety and welfare of service users who use bedrails are not in place putting them at risk of harm. Arrangements to make sure that the service continues to improve and to make sure that service users views are taken into consideration have not been fully put in place at this home. Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 22 The proprietor does not visit the home every month to make sure that the home is being run properly and ask service users their views about the performance of the service. EVIDENCE: The registered manger has considerable experience in a variety of care roles as well as a numerous years’ management experience at this care home. From observations and discussions, it is evident that the manager is sufficiently competent and skilled to carry out this role and has demonstrated the capacity to undertake additional training in order to update and expand her knowledge. She is completed National Vocational Qualification Level 4 in management which awaits assessment and has started an NVQ Level 4 in care which she is yet to complete. The home helps service users to manage their money. Detailed records are kept of service users finances and where staff have supported them to make purchases. Records matched the actual finances held by the home. Despite requests, the proprietor has not yet provided the Commission with details which demonstrate that the home is financially viable. . The proprietor has not carried out his responsibilities frequently enough. He has not visited the home every month to make sure that it is being run properly and write a report which gives his findings. The home is generally safe however staff have not received enough fire instruction training to make sure that they and service users are safeguarded in the event of a fire. And safeguards to make sure that bedrails are safe are not in place, placing one service user at risk. Although there are measures in place where service users are asked their views about how they would like to be supported, the services quality assurance programme has not been fully carried out. Clifford House DS0000007373.V309215.R02.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 Adults 18-65 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 2 2 Clifford House DS0000007373.V309215.R02.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. YA8 Standard Regulation 26 Requirement The responsible individual must carry out visits the home, complete duties specified by this Regulation and provide a report to the regulatory authority on a monthly basis. (Previous requirement from 1/4/ 2005 and 1/9/05). The registered manager must ensure that all staff have background checks carried out to confirm that they are suitable to work with vulnerable people before they take up employment at the home. All new staff must receive Induction Training to skills council specification within 6 weeks of appointment. The registered manager must ensure that all staff have one to one supervision at least every two months. The manager must have a qualification at level 4 NVQ, in care. A quality assurance programme must be fully in place at the home. Steps must be taken to ensure DS0000007373.V309215.R02.S.doc Timescale for action 01/03/07 2. YA34 19 15/12/06 3. YA35 18 15/12/06 4. YA36 18 01/02/07 5. 6. 7. YA37 YA39 YA41 9 24 17 30/06/07 01/02/07 15/12/06 Page 25 Clifford House Version 5.2 8. YA42 13 9. YA42 YA18 13 10. YA43 25 that all records required under the Care Homes Regulations 2001 are in place and well maintained. (Previous requirement from 1/3/05) Fire instruction training must be 15/12/06 carried out at the required frequency. (Previous requirement from 1/3/05) The installation, use and 15/12/06 maintenance of bedrails must meet current guidance and be undertaken by staff who are trained and competent in their use. (Previous requirement from 15/8/05) The owner person must submit a 01/02/07 copy of the annual business and financial plan to the Commission. (Previous requirement from 1/4/05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clifford House DS0000007373.V309215.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Clifford House DS0000007373.V309215.R02.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. 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