Inspection on 05/07/05 for Clifton House

This inspection was carried out on 5th 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

Clifton House 19/10/09

Clifton House 05/01/09

Clifton House 14/12/07

Clifton House 08/09/06

Clifton House 01/11/05

Clifton House 15/12/04

Clifton House 01/06/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Clifton House 1 Grantley Road Boscombe Bournemouth Dorset BH5 1HW Lead Inspector Julia Mooney Unannounced 5 July 2005 11:00am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Clifton House Address 1 Grantley Road Boscombe Bournemouth Dorset BH5 1HW 01202 393385 01202 303620 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) Mental After Care Association Mr Douglas Low CRH PC - Care Home Only 23 Category(ies) of MD - Mental Disorder (23) registration, with number of places Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five named adults (names known to CSCI) over the age of 65 years may be accommodated until such time as their assessed needs cannot be met by the home. Date of last inspection 15th December 2004 Brief Description of the Service: Clifton House is an older corner property situated in a residential part of Boscombe close to the sea and shopping centre. The accommodation comprises a ground floor with two residents accommodated in self contained units, a lounge in which service users can smoke, a smaller lounge, a separate dining room and a small quiet room for use by staff and service users. The staff office is also on the ground floor. The bedrooms are situated on the first and second floors. The home has 21 single bedrooms and 1 double. None of the bedrooms have en-suite facilities. Outside there is an garden with garden furniture and at the front of the building, car parking spaces for approximately 6 cars. The home accommodates a maximum of 23 service users who have mental health problems and at the time of inspection all bed spaces were occupied. The home is owned and managed by the Mental After Care Association. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and started at 11:00am on 5th July 2005. It was conducted as part of the normal routine of inspecting twice during a twelve month period. The registered manager – Mr Low, five service users and three staff all assisted the Inspector in the work. Methodology used included a tour of the premises, review of records and discussions with service users and staff. The inspector also reviewed the contact sheet for Clifton House and Regulation 37 reports submitted by the registered provider since the last inspection. Not all of the National Minimum Standards were assessed on this visit. Please note where a National Minimum Standard was not assessed the score is shown as x. What the service does well: The Registered Manager and staff at Clifton House are very committed to meeting the needs of service users currently accommodated at the home. Many have lived at the home for a number of years and are now over the age of sixty five. Staff at the home are very experienced in the field of mental health and continue to assess and meet the needs of these older persons. The home also accommodates younger, more independent people, whose stay at the home is fairly brief as their plan often includes the goal “to move into more independent accommodation”. A service user spoken with described the home “I have my own space”. “It’s flexible here, not too much routine”. Service users and staff were observed throughout the visit. There seemed to be a good relationship between staff and service users and staff appeared to enjoy working together. The atmosphere at the home was relaxed and informal. Prospective service users are given ample information about the home in order to make an informed choice about whether to live there. Staff encourage visits to the home prior to admission. Records evidenced that staff have excellent assessment skills so the needs and aspirations of service users are met. Service users spoken with confirmed that they were very involved in formulating their care plan. One stated “I see my care worker on a regular basis”. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 6 Records evidenced a good working relationship between staff and other health and social care professionals. Service users living at the home take part in a daily programme designed to give some structure to their day. Many attend day centres and drop in clubs in the community, others are in unpaid work. Records evidenced that service users enjoyed a wide range of leisure activities and have strong links with family and friends. The Registered Manager has a commitment to the health and safety of service users with staff receiving appropriate training. Suitable policies, procedures and risk assessments are also in place at the home. Health and safety records were well maintained and regular checks completed on all services and facilities. What has improved since the last inspection? What they could do better: No requirements or recommendations have been made as a result of this inspection. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 7 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. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1,2. The homes Statement of Purpose provides current and prospective service users with sufficient details to make an informed choice about admission to the home. Pre-admission and admission assessments are comprehensive to ensure that the needs and abilities of each service user is met EVIDENCE: Since the last inspection the registered provider has produced an updated Statement of Purpose/Service Users’ Guide which was examined by the inspector on this occasion. It contained relevant information about the home, including the aims, objectives, facilities and services. Service users spoken with confirmed that they received a copy of the homes’ Statement of Purpose/Service users’ Guide prior to admission. Clifton House is a home for people with mental health disorders so the care programme approach ensures that new service users are fully assessed by mental health practitioners. Comprehensive pre and post admission assessments are completed by staff at the home. Service users spoken with confirmed that they fully participated in their assessment/care plan. “Assessment prior to admission was very thorough and involved my Social Worker and staff from the home”. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 10 Records evidenced that there were thirteen service users at the home who were subject to various sections of the Mental Health Act 1983. Information pertaining to their restrictions and additional support requirements for these thirteen service users was available in their care plans. Records evidenced that the home was also able to meet the needs of two service users over the age of sixty five who had lived at the home for many years. A variation of registration approved in June 2004, allows the home to accommodate up to five named persons over the age of sixty five. The inspector was satisfied that current staff have the skills to work with any person with mental health needs irrespective of age, (care plans reflected this). Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 6,7,9 Service users spoken with confirmed that they were very involved in formulating their care plan to include their identified needs and how these goals and aspirations might be achieved. Service users are enabled to make decisions about their lives. Some service users have restrictions which form part of their daily living programme. e.g. they must return to the home by a certain time. Each person has a personal risk assessment on file with the aim of promoting independence. They are regularly reviewed, signed and dated by the service user and key worker. EVIDENCE: Each service user has a care plan generated from the single care management assessment/care plan. The inspector examined six care plans and found that they achieve a complete assessment of needs for each service user and detail how those needs are to be met. All sections of the care plans were completed and clearly involved the respective service user. The plans, which were signed and dated by the key worker and service user, are formally reviewed and any changes result in a care plan update. Service users confirmed that they were Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 12 fully aware of what was written in their care plans and that the plans were regularly reviewed. “I have recently had a 6 weekly review with my care coordinator and key worker which went very well”. Staff continue to maintain a high standard of recording in care plans. The home operates a key worker system and service users are seen a minimum of once a month. One service user commented “I can see my key worker whenever I like, she’s very helpful, I like her a lot”. Multi-disciplinary reviews are held annually From the sample of six care plans and key worker notes of sessions with individual service users, it was clear that staff respect service users’ rights to make decisions, staff were clearly very supportive and understanding of the client group. A service user spoken with said, “I have my own space and staff seem to respect this. I choose whether or not to go out, when to eat my main meal, staff are very accommodating. The home currently accommodates thirteen service users who are subject to various sections of the Mental Health Act 1983 so some service users day to day movements are restricted. The registered manager stated that the restrictions are discussed with them prior to admission to the home. Records examined recorded the restrictions. A service user spoken with said he had problem adhering to the “rules and restrictions. It just means I have to be back at the home by a certain time”. The registered manager stated that only seven service users are unable to manage their own finances. The home has a satisfactory system for issuing and receiving service user’s money. The home has very comprehensive risk assessments that are reviewed every six months or earlier if appropriate. Staff spoken with stated that they received training on how to complete the documentation. The risk assessments form part of the care plan. The six files examined all had a risk assessment and reviews and they were dated and signed by the service user and key worker. The home also has an environmental risk assessment for each service user which is reviewed every 10 weeks. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,15,16,17 Service users have ample time for activities, social interests and relaxation within the home and community. Service users maintain links with their families and friends and are encouraged to seek support and friendship in the wider community. Staff respect service users’ rights and recognise that they have a responsibility to enable service users to exercise as much control over their daily lives as possible. Meals offer choice and variety and special diets are catered for. Service users spoken with stated that they were involved in menu planning. EVIDENCE: Records indicated that one service user was in full time employment and is about to move on from Clifton House as the placement was so successful. A member of staff spoken with stated that one service user attends an Information Technology course on a weekly basis. Records indicate that key workers assist service users in finding courses/venues/placements for their Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 14 particular interest and support them in taking part in these activities. Records evidenced that many service users attended local day centres and drop in clubs. A service user informed the inspector that he attended day centres three times a week. One service user worked in a local charity shop on a voluntary basis and the care plan reflected this. Each service user has a social/leisure plan which includes staff supporting them to become part of and participate in the local community. Staff spoken with stated that “service users are encouraged to vote”. “Many service users use the library, cinema, local pubs and we often accompany them”. A service user spoken with said, “ I manage my own social life. I see my friends often and we go to the pub and I really enjoy going to the cinema, I’m going to see “War of the Worlds” this week”. The manager stated that one service user “enjoyed swimming and the home had use of a beach hut for a few weeks during May and June”. “Two service users attend church regularly and another attends sporadically and a local church invites service users to major events e.g. Harvest Festival”. Service users can receive visitors when and where they wish. Visitors arrived during the course of the inspection and went out with their relative accommodated at the home. Care plans at Clifton House state the level of contact/involvement the service user wishes to have with their families/friends. The home has a rota for service users to do the washing up after meals. Staff support some service users in using the laundry facilities and encourage and assist some with cleaning their rooms. Staff only enter bedrooms and bathrooms if needed. All bedrooms and bathrooms have locks which are accessible to staff in the event of an emergency. Service users have keys for their bedroom and the front door. All service users have a lockable space in their room. Personal mail is not opened by staff. Service users are able to choose when to be alone or in company subject to restrictions agreed in their plan. Two service users at Clifton House share a kitchen and a bathroom in separated accommodation on the ground floor to assist them with independent living. Care plans for these service users concentrates on rehabilitation type activities e.g. planning meals, cooking, self care, budgeting and seeking employment. The home employs a cook. Menus were examined by the inspector. They are changed every 4 weeks. The home offers a nutritious and varied diet taking into account service user’s preferences. Alternatives are available for anyone not wishing to eat the planned meal. The home now meets a requirement made a year ago to improve the homes’ system of service users “ticking” a box on a daily basis to indicate what they wished to eat that day. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 15 Service users now complete the menu choice each day and staff record what was actually eaten. Any special diets are noted. Breakfast time is flexible with service users helping themselves to a choice of cereals, fruit, toast etc. Lunch is cooked and is the main meal of the day, it is served at 12.30pm and there is always a choice. A light meal is served around 5pm; and beverages and snacks are available all day. Service users spoken with stated that they “help plan menus at the residents’ meetings”. A service user informed the inspector that “the home arranges for us to eat at different times if we go to day centres, drop in clubs or go out with family/friends, meals are put aside for us”. Fridge and freezer temperatures are recorded each day. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,20. Policies and procedures relating to the health care needs of service users promote good practice and ensure physical and emotional needs are met. Medication held at the home is well managed to ensure that service users medication needs are met and they are protected through the policies, procedures and practices of the home. EVIDENCE: The home uses 3 GP practices in Boscombe. Staff spoken with stated that “referrals are made to external professionals when required and service users to attend well woman and well man clinics”. Community Psychiatric Nurses, Social Workers etc visit service users regularly. Records evidenced that care of teeth and eyes are addressed in key worker sessions and appointments made as and when necessary. Occupational therapy input is available at the day centres attended by service users. Service users are regularly seen by the psychiatric team where their medication is constantly reviewed. A service user spoken with stated, “I saw my psychiatrist about six weeks ago, he was pleased with me and my medication can stay the same”. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 17 Records evidence that staff at Clifton House clearly have excellent working relationships with the health care teams in the area. Staff monitor service users’ health carefully and are suitably experienced to recognise a deterioration in mental health and the course of action to take. A staff member usually attends clinic and out-patient appointments with service users. In accordance with a requirement made as a result of the last inspection, the accident and incident record is now satisfactorily completed according to the home’s policy and procedure. The records were well maintained. Policies and procedures are in place regarding medication and there is a suitable system of storage, administration and disposal. There are no service users self medicating. The home uses the NOMAD system for dispensing. The record was examined and found to be satisfactorily maintained. Medication is administered by senior staff only. There is a stock control sheet for “as needed” medication and this was also recorded appropriately. The home has a disposal record which is signed by a staff member and the Pharmacist when stock is collected each week by the local chemist. The Pharmacist conducts an annual check and provides advice as and when necessary. All staff receive training in medication in their induction period and through further in-house training. The manager stated that two staff attended Medication in Care Homes training run by the Primary Care Trust. Certificates were available for inspection. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 18 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 standard(s) 22,23 Service users stated that “change occurs whenever a reasonable request has been made”. This assures service users that their views are taken seriously by staff. The home had satisfactory systems in place to protect service users from significant harm or abuse. This means that service users know they are safe and will be supported by staff whilst accommodated at Clifton House. EVIDENCE: A suitable policy and complaints procedure is in place at the home. The home has a formal record of complaints received. One verbal complaint had been recorded since the last inspection. The complaint was dealt with appropriately by the home. The manager checks and signs the record every three months and the documentation is re-evaluated by registered provider during her monthly visits. A service user spoken with said, “everyone is given the opportunity to voice their concerns, staff are very approachable and there are plenty of meetings where we can say if we don’t like something. Staff make sure things are changed, providing it’s a reasonable request in the first place”. The home has an Adult Protection policy and procedure. In accordance with a requirement made as a result of the last inspection, the procedure has been updated to make it an easy to read, step by step approach for staff to follow in safeguarding service users from abuse, suspected abuse or neglect. The procedure also includes the need for staff to contact the Commission for Social Care Inspection, complete and send a Regulation 37 report to the local CSCI office within 24 hours. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 19 The home also has a whistle blowing policy. The home supports the No Secrets local policy. Verbal and physical aggression in the home is dealt with by completing a risk assessment and acting on the instructions stated. The homes’ violence and aggression policy and procedure is appropriate. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 20 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 standard(s) 24,30. Clifton House provides a safe, homely and comfortable environment suitable for the needs of the current group accommodated there. The home promotes safe working practices in relation to cleanliness so service users are not at risk from infection. EVIDENCE: Clifton House provides a safe, domestic environment in which to live. A tour of the premises with the manager revealed that the first and second floor stairwell had been decorated and new stair carpet fitted. Two bedrooms have been decorated and re-carpeted. The self contained flat benefits from a new bathroom. A new front door has been fitted and there was new furniture in one of the lounges. The outside back garden has a newly created lawn and new garden furniture had been purchased. The front of the building now has a tarmac area where approximately six cars can be parked. The building and garden is well maintained and there is a cyclical maintenance programme in place. The manager stated that the kitchen in the self contained flat was next to be refurbished. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 21 The home keeps a maintenance book and a maintenance worker visits the home every 2 or 3 weeks to complete the tasks listed in the book. (Unless the work or repair is urgent, in this case it is done immediately). There is a renewals and replacement programme in place. All bedroom windows are fitted with restrictors. The manager stated that the home’s environmental risk assessment is reviewed every 10 weeks. Records were available for examination. Clifton House meets the requirements of the local fire service and environmental health department. Clifton House was found to be clean, tidy and comfortable and free from any offensive odours. Laundry facilities are sited outside the main building. Staff encourage service users to follow hygienic practices. The home has a satisfactory control of infection policy and procedure and staff spoken with confirmed that they had received training in this area. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 22 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35. The home has a comprehensive recruitment policy and procedure that ensures service users are not at risk. Service users are supported by a sufficient number of social care workers who are suitably trained and qualified offering consistency of care within the home. EVIDENCE: Three staff files were examined on this occasion. All relevant information relating to recruitment was evidenced. Files were very comprehensive. A thorough recruitment procedure was clearly adhered to, files evidenced application forms, interview notes, police checks, two written references, a letter confirming their appointment, contract and terms and conditions of employment. A new member of staff spoken with confirmed that after her interview, she received a letter confirming her appointment at Clifton House and this was duly followed by a contract and terms and conditions of employment. Staff records evidenced that all staff at Clifton House are experienced in caring for people with mental health problems. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 23 A new member of staff spoken with confirmed that she received comprehensive core standards induction training in line with TOPPS induction programme. “Training is the best, I’ve attended many courses already, they include health & safety, equal opportunities and moving and handling. Staff records evidenced that MACA has a range of courses on offer to staff and that the current staff group has attended a wide range of appropriate training courses. The manager stated that their training and development section at Head Office has a set budget for this purpose. He also said that Clifton House has had a training needs assessment for the staff group as a whole. Staff files evidenced that two members of staff are working towards NVQ level 3. One member of staff has a relevant degree and another has a Social Work Qualification. The manager has NVQ 4 in management and the Registered Managers Award. Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 24 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42. Service users are given the opportunity to make their views known and to feel they have some input into what happens in the home. This ensures that service develops in the best interests of service users. The health, safety and welfare of service users and staff are protected by suitable policies, procedures and practices at the home. This means that they can be confident of management support and guidance whilst living or working there. EVIDENCE: MACA has formal systems in place for reviewing the home’s aims, objectives and services provided. Quality assurance is monitored monthly by the area manager when she visits the home. The inspector receives these monthly reports. The home distributes annual questionnaires to service users and staff and the information is collated and included in the home’s annual review report. The Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 25 manager stated that service users receive a copy of the results of the questionnaires they completed. The inspector spoke with three service users about questionnaires but their responses were vague, one thought she completed a questionnaire. The manager also stated that the home also canvassed the views of Social Services and Primary Health Care Teams on the quality of care at Clifton House by using questionnaires, and again, the results are published in the home’s annual review report. The minutes of the current annual review meeting was available for inspection and confirmed the manager’s account. The meeting was clearly very much a team effort. The manager ensures that all staff comply with the organisation’s policies and procedures regarding Health & Safety. The home keeps a staff Health & Safety training schedule. All mandatory courses were listed and whether staff had current certificates or needed training or course update. Certificates were available for inspection. The has been no reports of Injuries, Diseases and Dangerous Occurences under RIDDOR regulation 1995. Records evidenced valid gas and electrical certificates. Portable appliances are due to be tested in March 2006 and records were available to evidence that the autolift was contractually maintained. Water temperatures are recorded monthly, the temperature is maintained around 43 degrees. Hot water outlets have thermostatic control valves. The record was examined by the inspector and found to be well maintained. There was also evidence that the home had a satisfactory result regarding a water test for Legionella Disease. Fire records were examined and found to be well maintained. All staff at the home including relief staff receive fire training every 3 months Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 26 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 4 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 4 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clifton House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 27 NO 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 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. Refer to Standard Good Practice Recommendations Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF 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 Clifton House D55 S3930 Clifton House V235277 050705 Stage 4.doc Version 1.40 Page 29 - 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!