Inspection on 26/04/07 for Clifton House (77)

This inspection was carried out on 26th April 2007.

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 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 (77) 01/04/08

Clifton House (77) 27/06/06

Clifton House (77) 09/02/06

Clifton House (77) 06/10/05

Clifton House (77) 03/03/05

Clifton House (77) 13/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Clifton House (77) 77 Brighton Road Coulsdon Surrey CR5 2BE Lead Inspector David Halliwell Key Unannounced Inspection 26th April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clifton House (77) DS0000025770.V336744.R01.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton House (77) Address 77 Brighton Road Coulsdon Surrey CR5 2BE 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) 020 8668 3330 020 8668 6667 clifton@sparshotts.freeserve.co.uk Mr Stephen Sparshott Mr Stephen Sparshott Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Clifton House is a detached extended, residential property situated in Coulsdon that is registered with the Commission for Social Care Inspection to provide care and accommodation for up to 16 older people of either gender. The home does not provide nursing or intermediate care. Communal areas comprise of a spacious lounge/dining area, separate quiet room / visitors facility, a private telephone room and gardens with patio area that is accessible via steps or a ramp for wheelchair users. The property stands on a main road and there is ample off-street parking to the front. The home has the usual additional facilities such as toilets and bathrooms on each floor and a laundry, office and kitchen. There are twelve single and two double bedrooms and six of the single rooms and both the double rooms have en-suite facilities. The owner of the home is also registered as the manager for the service. The home’s philosophy of care is stated as Clifton House aims to provide its service users with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance Fees charged are £373.80 and were accurate at the time of this inspection. Additional charges may be payable for some extras but would be discussed prior to admission. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the new Inspector responsible for Clifton House. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 1 member of staff and the Manager / Owner of the home. 4 service users were spoken with formally and more informal interviews were conducted with 6 other Service Users as a part of the tour of the home. 7 new requirements have been made as a result of this inspection, all of the previous requirements have since the last inspection been met. 2 new recommendations have been made and 1 of the previous recommendations remains in place, as it has not yet been met. Feedback on these requirements and recommendations was given verbally to the Manager at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the Manager and of the staff group. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £388 per week. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health care needs of service users are being well met. Service users are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Service users generally presented as well settled in their environment, and very satisfied with the communal and personal facilities provided. The home is being managed by the Owner in an open, professional and competent manner by Mr. Stephen Sparshott. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Specific improvements are now required and recommended in the following areas: 1. Staff training in Protection of vulnerable adults and in supervision. 2. Regularisation of the supervision process. 3. All staff to be provided with the chance to read, discuss and agree to the homes policies and procedures formally. 4. That the Manager ensures that all the staff receive POVA and other essential training identified in this report at least once every 3 years 5. Individual staff training files to be developed. 6. That as a part of the QA process visiting professionals e.g GPs; chiropodists; opticians; dentists and care managers are given the opportunity to comment on services provided to the residents. Also that a summary of the feedback information be provided to residents. 7. That: • A supervision-recording format is used that covers the areas outlined above in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. • That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 7 months. This should help to ensure consistency in the delivery of supervision. • That all staff should be given a copy of their supervision record following the supervision meeting. 8. The Manager / owner should undertake a regular audit of accident records to identify if any patterns or trends are forming e.g. recurrent falls. 9. That emergency lighting tests be carried out every 6 months and the results recorded. 10. A new check on the home’s electrical system in required. 11. That the unfinished refurbishment work in the kitchen be completed. Specifically: o The tiling and grouting, o The lighting unit needs to be fully cleaned and o The cooker hood and splash backs must now be installed Also that o 1st floor bathroom now needs to be completed, specifically the tiling and grouting and the cupboard doors. 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. The summary of this inspection report can be made available in other formats on request. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 is not applicable to this home as it does not provide intermediate care. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may be assured that their needs will be thoroughly assessed and reviewed by their referring agencies, they may also be assured that their needs will continue to be fully assessed at Clifton House and that fully completed documentation will always be held on their files. EVIDENCE: Standard 3 - As a part of the inspection the Inspector examined 4 service user files of the 15 residents living at Clifton House. In each of these files a comprehensive needs assessment was seen. The Manager / owner told the Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 10 Inspector that the referring authorities will usually provide an assessment of the prospective residents needs prior to admission. The Manager of the home then undertakes a thorough in house assessment of all prospective service users needs prior to a decision being taken regarding admission. This includes an assessment of the person’s health, risk factors, mobility and the compatibility of the person to ‘fit in’ with the current service users. The assessment is completed with the service user, his/her relative or representative and with the relevant professionals that have been associated with the referral. Religious and cultural needs are a part of the needs assessments seen in the resident’s files and all care plans are based on the information contained in the needs assessments. The Manager told the Inspector that care plan reviews are held quarterly or earlier if resident’s needs change and that these reviews involve the service users, their relatives and families and the home’s care staff. This was confirmed by residents, staff and relatives with who the Inspector spoke as a part of this inspection. Standard 6 - Intermediate care is not provided for at Clifton House so this Standard has not been assessed. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that their health, personal and social care needs will be the central focus of their care plans and that these plans will be appropriately reviewed as and when required. Service users can also be assured that their healthcare needs will be met at Clifton House. Medication administration is being appropriately managed and properly recorded and stored, and residents are being protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 12 Standard 7 – As indicated above the Inspector examined 4 residents’ files and found that on each file appropriate needs assessments had been drawn up. Service user plans / care plans had been constructed from these needs assessments and the Inspector was impressed with the detail covered in these plans. All the care plans inspected were seen to be reviewed quarterly or earlier if the needs of the residents change, the date of the review being recorded on file. It was clear from the care plan records held on the files that all the appropriate people are usually involved in the care plan reviews including the resident and their relatives where appropriate or their representatives. The Inspector spoke to a friend of one of the residents who also confirmed that their friend’s care plans are being reviewed and that the resident is normally involved in the process. The Manager / owner informed the Inspector that after the initial placement of a new resident an intermediate care plan is now being drawn up before the 6week review. After the 6-week review, the care plan is revised and then reviewed monthly. The Manager said that the LA Care Managers usually review a new placement 3 months or 6 months afterwards, however thereafter further LA reviews are rare. On each of the 4 resident’s files inspected the Inspector saw risk assessments. These risk assessments covered essential areas for the residents such as the risk of falling within the home. These risk assessments were seen to have been reviewed and updated where appropriate. The previous requirement has now therefore been met. All the documents required under Schedule 3 were seen on the residents files inspected. On one residents file a photograph was missing but the Manager assured the Inspector that he would put a new photograph on the residents file straight away. Standard 8 – This standard is concerning the healthcare of each of the service users. The Manager / owner informed the Inspector that all the service users do have access to a GP. The Manager also told the Inspector that all residents have access to the following health care professionals who visit Clifton House on a regular basis. The optician visits regularly, the dentist visits once every 6 months and the chiropodist also visits on regular basis. This information was also supported by the residents and staff who the Inspector spoke to over the course of this inspection. The Manager informed the Inspector that dietary needs are not assessed for service users as a matter of course, although if any resident has any special dietary needs then a nutritional assessment could be arranged. Standard 9 – The Inspector was provided with the agencies policies and procedures manual by the Manager and this file included an appropriate medication policy for the unit. The Manager told the Inspector that the usual Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 13 practice for the administration of medicines at Clifton House is for care staff to give the residents their medication. At the last inspection a requirement was made to ensure that all care staff receive training on the safe handling of medication. The Manager informed the Inspector that all staff have now received appropriate training to ensure that this is done safely and the residents are protected by safe and appropriate practices. Training certificates from Boots the Chemists that offered the training, were presented to the Inspector for the care staff, confirming their attendance. Training was held in November and December 2006. Appropriate records (MAR sheets) were seen to have been completed properly for the administration of medicines to service users. Together with the Manager the Inspector carried out a random stock take check of the medicines held in the home’s medicine cabinet and the numbers indicated on the MAR sheets. These tallied appropriately confirming that the administration and storage practices staff are using are accurate and appropriate. Standard 10 - The Inspector spoke with 6 of the 15 residents at Clifton House about the quality of the care they receive to meet their needs. The Inspector was impressed with the positive remarks made by service users about the care and support that they receive from staff at Clifton House. The Inspector was also impressed by the commitment of the staff, formally interviewed by the Inspector, to maintaining the dignity and privacy of the residents wherever possible. All the residents receive personal care and some are helped with washing and bathing, dressing and toileting. Care staff interviewed showed the Inspector by their responses their caring attitude towards the residents and service users in their comments about staff also reflected this. All of the bedrooms have en suite toilet and washing facilities and this also helps residents to maintain a level of privacy that they welcome. The staff induction programme which all new staff has to work through covers the core standards of privacy, dignity, independence, civil rights, fulfilment and choice. Evidence seen by the Inspector on the staffing files showed that most staff had received this training. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users / residents are likely to find that the lifestyle they experience at Clifton House matches their expectations and their preferences and satisfies their social, cultural, religious and recreational interests. Residents are encouraged to maintain contacts with their friends and families and service users are helped to exercise choice and control in their lives wherever possible. The meals and food provided to residents is well balanced, healthy and varied. EVIDENCE: Standard 12 - During the course of this inspection the Inspector was told by the Manager / owner about the different entertainments and social activities, which are provided for the residents. The Manager informed the Inspector that Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 15 the home employs an entertainer / activities person who works one day a week at Clifton House and who organises exercises and appropriate activities for the residents such as carpet bowls, reminiscent talks, quizzes, bingo and sing songs. The Inspector noted that many residents said they enjoyed this input. A previous requirement made to ensure this important area of activities for residents was improved, has now therefore been met. The Manager informed the Inspector that the resident’s religious and cultural needs are assessed as a part of their initial assessment and placement at Clifton House. A catholic and a C/E minister both visit the home weekly and residents are encouraged to attend the services if they wish to and staff will assist them to do so. 2 residents told the Inspector how they enjoy the opportunity to participate in Holy Communion. Standard 13 – The Inspector was told by the Manager and the staff that there are no specific visiting hours and that as long as a resident wishes to see a relative then visitors are welcome at most times of the day. A record of visitors was seen and visitors can be entertained in communal areas as well as the resident’s own bedrooms where relatives, families and friends can be seen in private if they wish. Residents confirmed this with the Inspector and the Inspector spoke to a friend of one of the residents in the resident’s bedroom at the time of her visit. At the last inspection a requirement was made that required an increase in community based activities for the residents. At this inspection the Manager told the Inspector about the current level of activities that does seem to mark an improvement for the residents. 4 residents interviewed by the Inspector confirmed that there has been an improvement in the range and scope of what is available for them to do, this requirement has now been met. Standard 14 – This standard explores issues relating to: managing financial affairs, advocacy, respecting of the right to personal possessions, and enabling access to information kept concerning a service user. One service user still has some control over their own affairs and the Manager told the Inspector that this is encouraged, where appropriate, and is assessed on admission to the home. The Inspector interviewed the resident is who is able to do so, and who evidently enjoys maintaining this level of self-determination and independence. The Manager informed the Inspector that the home does not handle or control any of the resident’s finances and where residents are unable to do so for themselves, relatives deal with these affairs on their behalf. Standard 15 – As a part of the inspection the Inspector spoke with the Manager at length and discussed the menu planning and the food provided to the residents. The Manager informed the Inspector that there is a rolling menu plan that is drawn up after consultation with the residents at the Residents meeting, who are asked what they would like to eat. He also said that on most days he goes out and does the shopping himself and any special dietary Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 16 requirements or individual daily requests are taken into account and provision is made in the menu plan and in the shopping purchased. The Inspector saw both the menu plan and the daily menus and these menus provide a wide and healthy range of food for the residents. The Inspector was present for the lunch and was able to speak to the residents at these times about the food. All the residents who were asked by the Inspector said that they like the food on offer to them and they confirmed that they do have a choice. Care staff was seen to provide assistance to the residents when this was necessary and staff were seen to ask the residents before they offered any help to them. Meal times were seen to be unhurried and any resident who chose to eat in their bedrooms was enabled to do so. The Manager informed the Inspector that the kitchen has recently been refurbished following an environmental health inspection carried out last year. The refurbishment however still has a number of unfinished areas and a requirement is now therefore made for the unfinished work to be completed. They are: 1. The tiling and grouting, 2. The lighting unit needs to be fully cleaned and 3. The cooker hood and splash backs must now be installed. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home will deal with complaints appropriately; information about the complaints procedure is readily available to all who may wish to express an opinion about the service. Service users can be assured that the processes in the home will protect them from potential abuse by staff or others. However staff training needs to become more regularised for all staff working in the home. EVIDENCE: Standard 16 – The Manager / owner showed the Inspector the complaints policy and procedure for Clifton House. This policy covers all the essential areas required for a complaints policy including a staged process with timescales and contacts for other agencies including the CSCI to contact in the event of dissatisfaction with the internal process of investigation. The Manager maintains a record of complaints and the Inspector saw this. No complaints had been recorded since the last inspection. A copy of the Complaints procedure and log record is kept on the residents’ notice board with a book available to document any complaints or concerns. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 18 After speaking with residents, it was clear that people who live in the home have great confidence that their concerns would be dealt with. This view was also reflected through reading the responses made by relatives on their comment cards. Standard 18 – Clifton House has an Adult Protection policy and the Registered Manager showed the Inspector a copy of it. Of the staff training records inspected it was confirmed that 3 of the 8 staff had not yet been on training for the protection of vulnerable adults (POVA). It is therefore now required that the Manager ensures that all the staff receive this training at least once every 3 years. At this inspection the Inspector identified a need for more regular and comprehensive training for all staff in the key areas of protection and practice. This should include the following areas: • Manual handling • Food hygene • Health and safety • 1st aid • fire prevention / safety • medication • POVA • Infection control Discussions through supervision should further embed the principles of the policies and practices that staff have been trained on. The Inspector discussed this with the Manager and it was agreed that further discussion needs to be had with staff in the supervision process. Staff members are all thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register have been checked. The home’s policies and procedures cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. There are sufficient organisational policies to safeguard the residents welfare e.g. dealing with abuse and a whistle blowing policy. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. Residents generally presented as well settled in their environment, and as being very satisfied with the communal and personal facilities provided. EVIDENCE: Standard 19 – A tour of the premises was undertaken by the Inspector with the Manager as a part of this inspection and the home was seen to be clean and tidy in all areas. All areas of the home are accessible to wheelchair users Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 20 and there is a lift that provides access to both floors of the building. There are at present no residents who use a wheelchair living at Clifton House. The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The Manager /owner provides a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. Refurbishments to the kitchen need now to be completed and this has been referred to earlier in this report. Similarly completion of the refurbishments to the 1st floor bathroom now need to be completed, specifically the tiling and grouting and the cupboard doors. One or two residents said that they like to do a little bit of gardening with support from the staff. The Manager showed the Inspector the fire records for the home. The LFEPA last visited Clifton House in August 2005 at which 2 requirements were made. The Inspector viewed each requirement and can now report that one has since been met (carried out on 1.8.06) to do with a fire risk assessment for the building and another has not yet been carried out. This is now made a requirement and refers to the need for emergency lighting tests to be carried out every 6 months and the results recorded. Records were also shown to the Inspector by the Manager for other safety checks that have been carried out this year and that are part of a regular process of checks carried out to help ensure the safety of the residents. Records of the following satisfactory checks were seen: • Lift – 12.3.07 • Environmental health – food hygiene 4.5.06 – recommendations were made for the kitchen to be refurbished and this has already been mentioned earlier in this report. • Fire protection and alarm system – 1.3.07 • Fire extinguishers – 8.3.06 Checks on the hot water outlets are also now being regularly checked and temperatures recorded. It was highlighted at a recent inspection that the ongoing programme of refurbishment and redecoration should be documented to show how the home monitors the upkeep of the premises and does make improvements where necessary and this had been made a requirement. The Manager / owner showed the Inspector an annual development plan for 2006 and 2007 which he had drawn up following a comprehensive assessment of these needs in and around the home. Together with the Inspector, the Manager ran through each of the items listed in order to monitor the progress that has been made against the timescale for achievement. Several items have been achieved but there are Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 21 also many that have not. It is strongly recommended that the Manager now ensure all timescales are met appropriately. However the previously made requirement has now therefore been met. Standard 26 – As already indicated above, the home was found at this inspection to be clean, tidy and free from offensive odours. The Inspector toured the unit together with the Manager and inspected all areas of the home. Several of the service users bedrooms were seen and were found to be clean and tidy and all the residents spoken to by the Inspector said that their bedrooms are decorated and furnished as they would wish. The Manager showed the Inspector the home’s infection control procedure, which seems to be effective. Staff interviewed confirmed that they are issued with appropriate clothing (disposable gloves and aprons, uniform jackets) and equipment for them to carry out their work appropriately. The laundry area is well laid out and there is an impermeable floor laid down to prevent water ingress and easy cleaning. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, these need to be more robustly applied. Records are being maintained, with staff photographs, as proof of identity, now being attached to staff files. Staff are being provided with the necessary induction and training with which to competently perform their work duties. EVIDENCE: Standard 27 – the Inspector asked for a copy of the staffing rota for Clifton House. The rota shows exactly who is working for the week. The Manager informed the Inspector that there are usually 2 care staff on duty for the am shifts and 2-3 care staff for the pm shifts. A manager is on duty during the day and on call at nights. There are always 1 waking night staff on duty and 1 on call. The rota provided supported this statement. Given that that there are 15 residents living at Clifton House at present the staff: resident ratio mix seems adequate to meet the needs of the residents. The Manager told the Inspector that no agency staff are used at Clifton House. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 23 Standard 28 - The Manager / Owner explained to the Inspector that not all the staff group have at present achieved an NVQ level 2 but that plans are in hand for this to be reached by the end of this year. Of the 12 care staff 5 hold an NVQ at level 2 or above. Only the Manager / owner holds an NVQ level 4 qualification which means that the Deputy Manager will also need to gain an NVQ this year. The Manager explained that no agency staff are used in the home. Standard 29 – Clifton House does have a recruitment procedure that was inspected and seen to be appropriate for it’s purpose. As a part of this inspection the Inspector reviewed 9 of the staffing files. Applicants are interviewed, application forms completed, two written references gained, enhanced Criminal Record Bureau checks undertaken and documentation regarding all these parts of the recruitment process are held on staffing files in the office at Clifton House. On the files inspected the Inspector saw evidence that this process is being properly implemented. Contracts with staff were also seen on most of the staffing files and the Manager confirmed that he would ensure that copies of all staff contracts following this inspection would be placed on the files. Standard 30 – The home has a programme of induction in place. This covers staff roles and responsibilities, and key policies and procedures. Induction is ongoing for up to a month with observation, shadowing from an experienced staff member and ongoing assessment. The Manager told the Inspector that the staff induction training does include fire, manual handling, food hygiene and health and safety. With regards to staff competency it is important that all staff are familiar with the home’s policies and procedures. The Inspector asked the Manager if staff are given the opportunity to read and discuss these policies and procedures as a part of the supervision process and whether they are then asked to sign to say that they have read and understood the same policies. The Manager said that this practice had been carried out however on inspection it was found by the Inspector that not all staff had signed to say that they had read and understood all the home’s key policies and procedures. In order for this process to be fully implemented and so as to benefit residents in that the staff will know and understand what the stated policies and procedures are, it is now a requirement that all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective residents may be assured that the home is well run and managed by a person who is fit and able to be in charge of the day-to-day operations of the unit. They will benefit from the leadership and management approach taken in the unit. The quality assurances processes now being used in the home should ensure that it is being run in the best interests of the residents and residents financial interests are safeguarded. Staff are supervised regularly however the process being used needs some regularisation and improvement. The health and safety of staff and residents is being promoted and protected. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 25 EVIDENCE: Standard 31 – The Manager and Owner has been in the management role at Clifton House for over 2 years and holds the necessary experience and management qualifications to undertake this role. Standard 33 – Following a recent requirement to develop and improve the quality assurance (QA) programme the Manager told the Inspector that a number of new processes have since been developed. These ensure that the process of monitoring the agency’s outcomes for residents has improved. (QA) is through formal and informal consultation with service users and from visiting relatives and professionals. Feedback forms are now issued and questions asked which focus on the key principles of the service e.g. privacy, dignity, independence, choice, rights and fulfilment. The information and feedback gathered from these sources is then analysed and monitored by the Manager. The Inspector asked the Manager if visiting professionals e.g GPs; chiropodists; opticians; dentists and care managers are given the opportunity to comment on services provided to the residents and whether a summary of the feedback information is provided to residents. The Manager agreed that this is a new area that should be developed and he told the Inspector that this will now be addressed forthwith. Feedback information from the surveys and other aspects of this process could be provided to residents via residents meetings and newsletters. This is a requirement. The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with service users. Standard 35 – The Manager told the Inspector that Clifton House does not look after resident’s monies directly and therefore this Standard was not inspected. Standard 36 – The Manager informed the Inspector that all care staff receive formal supervision at least once every 3 months and informal supervision more often, sometimes on a daily basis. Some supervision records were seen by the Inspector in the staffing files inspected, however they did not reflect the frequency stated by the Manager and they had not been signed off by staff in agreement with the record made by their supervisor. The records were also quite varied in their recording content, some not covering sufficient detail to form a useful record. The Inspector spoke with the Manager about this and confirmed that supervision sessions held with staff should include the monitoring and review of all aspects of care practices, the philosophy of care in the home and also Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 26 career and training development needs. Areas of discussion should also cover the monitoring and review of any individual work objectives that the staff member is expected to carry out. The supervision record should detail any agreements made, revised work objectives, key areas of discussion and should be signed off by both the member of staff and the supervisor. Staff who are supervised should be given a copy of the supervision record which they may keep in their staff handbook file. The care staff interviewed confirmed that they receive supervision on a regular basis and that formally they receive supervision approximately once every 2 – 3 months and that they have informal supervision much more regularly. Staff said that they did not receive copies of their supervision records. The Manager would like to suggest that future training on staff supervision needs to be planned for next year and a training course programme be shown to the Inspector. This should help to ensure that supervision and staff appraisals are carried out consistently and effectively. Appropriately structured policies were seen by the Inspector for induction, training and supervision in the home’s policies and procedures manual. It is a requirement that following the inspection of this standard that: • A supervision-recording format is used that covers the areas outlined above in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. • That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. • That all staff should be given a copy of their supervision record following the supervision meeting. Standard 38 - The Manager showed the Inspector the maintenance record for the home which details all the maintenance requirements and how and when they have been resolved. The home is generally well maintained and the process seems to work well. The Manager informed the Inspector that risk assessments have been carried out for fire risk on 1st august 2006 and that individual risk assessments have been carried out for the residents in the unit and evidence of this was shown to the Inspector. The policies and procedures manual includes policies on health and safety, risk assessment, moving and handling and fire. Some staff have been trained over the last 2 years in the following areas: • Infection control • Food hygiene Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 27 • • • • • • First Aid Fire prevention Health & Safety Safe handling of medicines Moving and handling POVA However there is a need for all staff to receive more regular training in these key areas and it is recommended that for each staff member a training file is compiled which includes a list of training that each staff member has received and when; certificates which evidence that the training has been given and received; and a list of training needs identified through 1:1 supervision that should be provided for by additional training in the year ahead. Certificates were checked and seen by the Inspector for the following services that are installed in the home, certificates which state that these systems have been checked by appropriate professionals since the last inspection and found to be satisfactory and fit for purpose. 1. Boiler / gas – a brand new installation recently fitted for hot water and central heating 2. Electrical system check – last completed on 12.2000, a new check is now needed 3. Lift – 3.07 4. Fire bells – 2006 5. Emergency lighting system – 2006 6. Fire fighting equipment – 2006 7. Portable electrical appliances – 3.07 Records were also seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests – last 20.4.07 2. Staff fire drills every 2 months 3. Fire extinguishers visually checked monthly 4. Hot water outlets checked weekly 5. Fridge and freezer temperatures checked daily 6. Food temperature checks daily. Under Standard 19 a new requirement has been made that refers to the need for emergency lighting tests to be carried out every 6 months and the results recorded. All accidents and incidents are recorded appropriately (records seen by the Inspector) and clear safety notices are posted throughout the home. It is however recommended that the Manager should however undertake a regular audit of accident records to identify if any patterns Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 28 are emerging that may require changes in staff practices regarding residents falls. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 16 Requirement That the unfinished refurbishment work in the kitchen be completed. Specifically: 1. The tiling and grouting, 2. The lighting unit needs to be fully cleaned and 3. The cooker hood and splash backs must now be installed To the 1st floor bathroom now need to be completed, specifically the tiling and grouting and the cupboard doors. The Manager ensures that all the staff receive POVA and other essential training identified in this report at least once every 3 years That emergency lighting tests be carried out every 6 months and the results recorded That all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time DS0000025770.V336744.R01.S.doc Timescale for action 26/06/07 2. OP18 13 30/07/07 3. 4. OP19 OP30 13 18 30/05/07 30/07/07 Clifton House (77) Version 5.2 Page 31 5. OP33 24 6. OP36 18 7. OP38 13 and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. That as a part of the QA process 26/06/07 visiting professionals e.g GPs; chiropodists; opticians; dentists and care managers are given the opportunity to comment on services provided to the residents. Also that a summary of the feedback information be provided to residents. That following the inspection of 26/06/07 this standard that: • A supervision-recording format is used that covers the areas outlined above in sufficient detail to ensure a useful record is maintained for both the staff and the management if the need arises in the future. • That all senior staff who provide supervision should receive staff supervision training and that this should be completed within the next 6 months. This should help to ensure consistency in the delivery of supervision. • That all staff should be given a copy of their supervision record following the supervision meeting. That a new Electrical system 30/05/07 check is now carried out. Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 32 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 OP38 Good Practice Recommendations The registered provider should undertake a regular audit of accident records to identify if any patterns or trends are forming e.g. recurrent falls. (Repeated from October 2005 inspection) That for each staff member a training file is compiled which includes a list of training that each staff member has received and when; certificates which evidence that the training has been given and received; and a list of training needs identified through 1:1 supervision that should be provided for by additional training in the year ahead. 2. OP38 Clifton House (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 (77) DS0000025770.V336744.R01.S.doc Version 5.2 Page 34 - 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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