CARE HOME ADULTS 18-65
Clifford Lodge 12 Clifford Road Blackpool Lancashire FY1 2PU Lead Inspector
Mr Wesley Cornwell Unannounced Inspection 10th October 2005 09:30 Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 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 Lodge DS0000064036.V250457.R01.S.doc Version 5.0 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 Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Clifford Lodge Address 12 Clifford Road Blackpool Lancashire FY1 2PU 01253 28793 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) Pro-Care Disperse Housing Ltd Mrs Jacqueline Lesley Berry Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 6 service users with a Mental Disorder, excluding learning disability or Dementia (MD). 25th April 2005 Date of last inspection Brief Description of the Service: Clifford Lodge is a care home registered for 6 young adults with mental health problems aged 18 to 65 years. The home is situated in the North Shore area of Blackpool close to the town centre. The accommodation provides 6 single rooms which are located on the first floor. Toilet and bathing facilities are also located on the first floor. There is no lift available at this home. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30am and took place over three hours. The Inspector spoke to one staff member, four residents, one Health and Social Care Professional and the manager. Comment cards were completed by three Health and Social Care Professionals providing their views about the home prior to the inspection. Staff and care records were also examined. A full tour of the premises was undertaken with the manager. One additional unannounced visit has been made to the home since the last inspection in April 2005. This visit was undertaken with a Pharmacy Inspector to monitor the response of the homes owners to requirements raised in previous inspections about the homes procedures for the administration of medication. What the service does well: What has improved since the last inspection?
Since the last inspection the manager of the home has become registered with the Commission for Social Care Inspection and has also been successful in achieving a nationally recognised management qualification. There have been some minor improvements made to the home since the last inspection. New tables have been purchased for the dining room and the lounge is being re-decorated. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 6 The risk assessment of the building has been reviewed and updated and a copy made available to the Commission as requested at 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 Lodge DS0000064036.V250457.R01.S.doc Version 5.0 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 Lodge DS0000064036.V250457.R01.S.doc Version 5.0 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): These standards were not assessed. EVIDENCE: Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 9 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): 9 Residents are supported to pursue an independent lifestyle with identified risks monitored and reviewed. EVIDENCE: The daily records of three residents clearly described the level of support and assistance being provided by the home with decision-making. Residents spoken to said the home was supportive in encouraging them to live independently with the knowledge that staff members are available to provide assistance if this is required. One resident said, “ I have my own car and can get out and about to see friends and family. I often have days out in my car with my partner”. The care plan records showed the home was working in partnership with healthcare professionals in assisting one resident with a referral to the Richmond Fellowship re-a possible move to having their own accommodation and independent living. Discussion with the manager and observation of care plan records confirmed the home has clear risk assessment management strategies in place for dealing with potential risks to residents. The home has a good record of dealing promptly with any unexplained absences of residents.
Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 10 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): 15 and 16 Visiting arrangements at the home are informal and family and friends of residents are encouraged to maintain contact ensuring personal relationships are maintained. Routines within the home are flexible and are arranged to ensure resident’s rights are respected. EVIDENCE: Residents said they were happy with arrangements in place for receiving their visitors and were encouraged by the manager of the home to maintain contact with their family and friends. One resident said, “ I see my family and friends all the time. They can visit me at the home or I can go and see them. The staff are great and always make my visitors welcome”. Health and Social care professionals said they were able to see residents in the privacy of their own room. Three residents said they were happy with the routines within the home and these were being arranged around their individual and collective needs. The residents said they were provided with the choice of spending time on their own or in the lounge areas and the manager and staff respected their privacy.
Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 11 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 Promotion of health is taken seriously and personal support is provided in a flexible and sensitive manner. EVIDENCE: Three residents said they were happy with the level of support they receive within their daily routines and could make their own decision when to bath, retire to bed and get up in the morning. The care plan of one resident showed the level of support being provided by staff members in making a decision about the resident’s healthcare problems. The resident said the staff had been great but they were being encouraged to make their own decision. Healthcare professionals said the manager and staff at the home demonstrated a clear understanding of the needs of residents and take appropriate decisions when they can no longer manage the needs of residents. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed. EVIDENCE: Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 13 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): 24,25,26,27,28,29 and 30 The lack of a planned maintenance and renewal programme for the redecoration and refurbishment of the home does not ensure residents live in a comfortable, homely and safe environment. EVIDENCE: There has been some limited progress in upgrading the environmental standards in the home since the last inspection. The lounge is in the process of being redecorated and some replacement furniture has been purchased for the dining room. A recommendation made during the last inspection was for the homes owner to provide two double sockets in resident’s bedrooms. There has been no progress in this area. Resident bedrooms are all in need of redecoration and refurbishment. The environment throughout the building would benefit from redecoration and refurbishment to ensure the continued comfort of residents. Residents spoken to were happy with their bedrooms and said the staff respected their privacy. One resident said, “ I am satisfied with my room. I have my personal possessions and like to spend time on my own”. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 14 The manager of the home has reviewed and updated a risk assessment of the building since the last inspection and this has been made available to the Commission. Toilet and bathing facilities are located on the first floor and are meeting the assessed needs of residents and offer sufficient personal privacy. It was observed during the visit the home was clean and hygienic. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 15 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 and 36 The policies and procedures for the recruitment of staff are robust and provide safeguards for the protection of residents. Staff are well trained to ensure they have the competencies to meet residents needs. The deployment of staff throughout the day is sufficient to meet the needs of residents. EVIDENCE: The home has a small staff team and turnover is low. The file of one staff member employed since the last inspection confirmed the necessary recruitment checks had been undertaken to ensure the protection of residents living at the home. The Inspector discussed with the manager the recruitment checklist completed confirming references and police clearances had been received. The Inspector was unable to identify when these had been applied for and received, as the form had not been dated. The homes procedures should be reviewed to ensure this information is clear. Records showed that training is being provided by the home. One member of staff said they had an individual training and development assessment, which had identified training needs and these were being met. Three staff members are working towards achieving National Care Qualifications. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 16 Staffing levels were sufficient for the number of residents living at the home. Residents spoken to were very positive in their comments about staff members and were happy with staffing levels. Healthcare professional’s said staff members were always available when they visited the home and seemed to be clear about their roles and responsibilities. Staff at the home demonstrate a good understanding of residents needs. They are well supported and supervised by the manager. One member of staff confirmed they receive formal supervision with the manager and had been able to identify training courses they would like to attend to update their skills and knowledge. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 17 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 and 42 The home is well managed and run in the best interests of residents. EVIDENCE: Since the last inspection the manager of the home has become registered with the Commission for Social Care Inspection and has also been successful in achieving a nationally recognised management qualification. Inspection of maintenance records confirmed facilities and equipment was being maintained as required. Records were available to the Inspector to verify that training on health and safety issues had taken place. Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Clifford Lodge Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000064036.V250457.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 YA24 YA26 YA32 Good Practice Recommendations The registered person should produce a programme for the routine maintenance of the fabric and decoration of the home. At least 2 double sockets should be provided residents accommodation. 50 of the care staff team should achieve NVQ qualifications Clifford Lodge DS0000064036.V250457.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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