CARE HOMES FOR OLDER PEOPLE
Clifton House (77) 77 Brighton Road Coulsdon Surrey CR5 2BE Lead Inspector
Claire Taylor Key Unannounced Inspection 27th June 2006 11:40a 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.V297053.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.V297053.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.V297053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th February 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.V297053.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. In accordance with the Commission’s “Inspecting for Better Lives” programme, all of those standards considered to be key to the inspection process were assessed. Time was spent talking to the residents and staff, one visiting relative and the manager /owner Mr Sparshott. Various records, policies and care plans were examined. The premises were viewed, as were several of the residents’ bedrooms. The total time spent in the home was five hours. Some information was taken from the questionnaire that the manager had filled in prior to the inspection. Nine written comment cards, completed by residents’ relatives or representatives, were received in respect of the service. “Have your say” questionnaires were left for the residents at the end of the inspection. Any findings will be included in the next inspection report. What the service does well: What has improved since the last inspection?
Arrangements have been made for an entertainer to visit the home each Monday and organise activities. Residents said they very much enjoy the sessions which have included a skittles game and quiz. The renovation of the upstairs bathroom was near completion and three bedrooms have been redecorated. There are plans to upgrade the kitchen and its facilities and the refurbishment work has begun. Recruitment practices have generally improved and in response to the last inspection, CRB checks have been obtained for all staff currently working in the
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 6 home. The majority of other staff records required by regulation have also been put in place although some further improvements are needed to maximise residents’ protection. These have been highlighted in the next section. What they could do better:
Some requirements are now outstanding from the March 2005 inspection and must be prioritised. The provider must therefore submit an action plan to outline how the home intends to address them as well as the new requirements outlines in this report. Ongoing failure to meet with outstanding requirements may result in the Commission taking enforcement action. The three outstanding requirements are outlined as follows. No progress has been made with the implementation of a quality assurance system and an annual development plan. The home must therefore actively seek the views of residents and their supporters to monitor satisfaction with the service provided. Although practices for recruiting staff have improved, the home’s policies and procedures still need updating. In addition, staff records must fully meet the legal requirements of the care homes regulations. I.e. for some staff, proof of health clearance is needed to evidence their fitness to work. A written programme of maintenance and refurbishment is still needed to demonstrate how repairs and upkeep of the premises are undertaken. Residents need to be given a copy of the Service Users Guide so that they have full information about the home and services provided. A detailed Statement of purpose about the home is available but room size measurements need to be specified. Property lists of each resident’s furniture and valuables need to be completed when they are admitted so that their personal property is better safeguarded. Although the home kept clear records of repeated falls for one resident, their mobility risk plan was not up to date. Staff must have clear guidance on what action to take when a person’s mobility needs have changed. The home needs to provide a wider range of recreational activities that addresses the social needs of the residents and provides more structure and stimulation. This should include more engagement in community-based activities. This was a view shared by some of the relatives and residents. To further maximise safe practice, staff still need to attend formal training in medication administration. Some areas concerning health and safety need attention. The overall electrical safety of the home now needs to be checked and the hoist must be serviced. The risk assessments related to safe working practices within the home also need to be reviewed. If left unchecked for too long, this could put people living and working at the home at risk. Finally, the two night staff must complete fire safety training including participation in a fire evacuation practice. Six good practice areas for the manager/owner to consider are outlined as follows. Staff should update their training on specific needs of some residents. I.e. Parkinson’s disease and Diabetes. The staff team would benefit from a designated activities coordinator and the home should keep records of all social and recreational activities that residents participate in. Net curtains should be
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 7 replaced in the dining area at the front of the house to ensure better privacy for residents. Repeated from the last inspection, the manager should undertake a regular audit of accident records to identify if any patterns are emerging concerning residents’ falls. 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 (77) DS0000025770.V297053.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.V297053.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home as it does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. Information about the home was available to prospective residents to make an informed choice although copies of such guides must be provided to individuals. The home carries out pre-admission assessments, ensuring that residents are appropriately placed and therefore receive the care that meets their needs. Property lists need to be drawn up however so that residents possessions are more fully safeguarded. EVIDENCE: A detailed Statement of purpose and guide is in place, which sets out in detail the home’s aims and objectives, and the services and facilities provided. One addition needs to be made however in that each room size / measurement needs to be specified. Residents, both current and prospective, must each be provided with a copy of the Service Users Guide so that they have information about the home and services provided. One resident spoken to said that they
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 10 had not been provided with a guide but said they spent a morning in the home meeting staff members and other residents before moving., The three newest residents felt that they were fully involved in the process leading up to admission and likewise, were given the opportunity to view the suitability of the home. The manager/ owner undertakes the pre-admission assessment that is usually completed with the resident, his/her relative or representative and the other relevant professional associated with the referral. Written admission documentation includes a questionnaire to establish any personal preferences of the new resident. Of the records checked, informative needs assessments had been completed. One shortfall however was that the home did not complete a check on the resident’s property or valuables that were brought into the home and this must be addressed. Clifton House (77) DS0000025770.V297053.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Care planning remains well organised and regular informal reviews ensure that staff are able to meet the individual care needs of residents. Some mobility risk plans need further development to fully safeguard individual residents from potential harm. Residents are able to access care from additional services so that their healthcare needs continue to be met. Medication practices are overall well managed although staff still need to attend formal training in medication administration to further maximise safe practice. EVIDENCE: The records of six residents who live at the home were sampled, including the three newest admissions. They each contained a detailed care plan that was initially based on the pre-admission assessment and addresses the health, personal and social care needs of each resident. There were details about how staff should support them, and about where the person was independent in meeting their needs. Records showed that residents’ care plans are reviewed each month so that any changing needs are identified and appropriate
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 12 amendments can be made. Likewise, daily care records indicated that individuals are consulted about the care that they receive. Risk assessments, that seek to protect residents’ health and safety were on file in respect of residents skin integrity, mobility, and nutrition (including weight monitoring) and other relevant areas. Accident records revealed a substantial number of falls had occurred concerning one resident over a period of four months. Although the home was monitoring the occurrences, the resident’s mobility risk plan had not been reviewed. This is important so that staff have clear guidance on what action to take when a person’s mobility needs have changed. Residents confirmed that staff respect their rights to privacy and dignity when receiving care and support. Staff members were also observed to consult with residents in a respectful manner during this inspection. Residents are in regular contact with General Practitioners, District Nurses and other health care professionals as required. I.e. hospital clinics, chiropody and optician. One resident receives regular visits from the district nurse for treatment of leg ulcers. The home keeps records of all healthcare appointments, in addition to individual progress notes. Procedures and practices regarding residents’ medication remain well managed by the home although staff still need to attend accredited training on safe administration. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to the service. Routines of daily living are made flexible and some activities are provided, although they should be increased to provide more interest and stimulation for residents. Residents are supported to maintain contact with their families and friends so that their social relationships continue. Wherever possible, residents are able to exercise choice and control in their day-to-day routines, and receive appropriate support from staff to achieve this. The meals provide choice, a balanced diet, interest and variation for the residents. EVIDENCE: Residents preferred social and leisure interests are recorded in their care plans although records did not evidence clearly what activities they were participating in. There is a notice board in the hall with information about activities and social events/ functions. The home arranges for residents to have their newspapers delivered daily as they so choose. A hairdresser visits weekly and came to the home during the inspection. Several residents said they look forward to her visits. Residents’ religious needs and beliefs are catered for and some individuals confirmed that they are supported to attend church of as their
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 14 faith so determines. A priest visits the home and several residents have the opportunity to participate in Holy Communion. Since the last inspection, arrangements have been made for an entertainer to visit the home each Monday and organise activities. Residents said they very much enjoy the sessions which have included a skittles game and quiz. One resident said “it would be nice if they came more often though”. Some improvements are still needed therefore regarding the home’s recreational activities. Although the staff do provide a number of activities, the lack of a designated activities coordinator does mean that there is not always enough stimulation for residents. This was a view shared by a number of relatives and residents. It would therefore be better if the manager allocated one or two staff to take responsibility for organising activities in the home. Several relatives felt that there needed to be more stimulation and availability of activities, including outings or trips in the local community. Visitors are always made welcome and one relative in the home gave positive views about the care provided for her relative and the caring attitude of the staff during her visits. Compliments about friendly and welcoming staff were also noted on comment cards received from relatives. The general care provided to residents was once again, observed to be sensitive and respectful. Residents are consulted about their meal choices each morning and food provisions are purchased accordingly on a daily basis. Menus were varied, balanced and provided choice. Staff served and assisted residents appropriately and sensitively with their cooked lunch during the inspection. Residents spoke very positively in respect of the food provided, flexibility of meal times and choice of meals. Comments included “the food is very good” and “the staff know us well and what we like to eat”. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to the service. An appropriate complaints procedure is in place to ensure that the views of residents, their families and friends are listened to and acted upon. The home’s practices have improved to more fully safeguard residents from potential abuse. EVIDENCE: 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. No complaints have been made either to the home or to the Commission for Social Care Inspection since the last inspection or within the last twelve months. Having spoken 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. There are numerous organisational policies to safeguard the residents welfare e.g. management of their finances, dealing with abuse and a whistle blowing policy. The majority of staff have attended an adult protection training course or undergone abuse awareness through the home’s induction training programme. One staff was able to describe the correct action to take if they suspected anything untoward including possible abuse. In response to the last inspection, CRB checks have been obtained for all staff currently working in the home. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to the service. The home is kept clean, hygienic and comfortably furnished so that residents live in homely and pleasant surroundings. Residents’ bedrooms appeared comfortable and pleasantly decorated, reflecting their personal identities, and being suited to their individual needs. EVIDENCE: The home remains well furnished, clean and comfortable for the residents. The refurbishment of the upstairs bathroom was near completion and three bedrooms had been redecorated. Some of the bedrooms were viewed with the permission of residents. They appeared comfortably furnished and decorated to a high standard. Residents have personalised their rooms as they so choose with family photographs and other personal possessions. Individuals can bring their own furniture into the home if they wish. Time was spent with one resident in her room who said that the staff were very helpful and that her room was always kept clean. Another resident confirmed that staff respond promptly to her call bell when she needs help or assistance.
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 17 The home appeared clean, tidy and free from offensive odours. Good hygiene practices are observed and systems in place to control the spread of infection. Clinical waste disposal remains well managed. As highlighted at the last two inspections, the ongoing programme of refurbishment and redecoration must be documented to show how the home monitors the upkeep of the premises and makes improvements where necessary. As good practice, the home should replace the net curtains in the dining area at the front of the house as it is situated on a main road and privacy for residents may be compromised. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. There is a stable staff team who understand and respect the needs of the elderly people living there. Progress has been made with staff training, however, some further development of care staff’s expertise on residents’ specific needs is still needed. Although recruitment practices have improved significantly, all checks must be obtained for all staff to maximise protection for the residents. EVIDENCE: Rotas were checked. Staff provision allows for three carers to be on morning duty, three in the afternoon with one waking and on call sleep-in staff at night. The manager or deputy manager is available during the day. These levels appeared adequate for the current resident group. Valuably, staff turnover remains low and most of the staff have worked in the home for many years. This means that residents benefit from a stability and consistency of care. Residents spoke favourably of the long standing staff and their caring manner. Records confirmed that the home meets the required standard for numbers of trained NVQ staff. Four staff files were checked, including one for the newest staff who joined in October 2005. One staff was interviewed and discussed their orientation to the home. They were able to correctly describe what to do if they suspected that a resident had been abused. The induction process for new staff includes in house training relevant to the needs of the residents. Sampled files contained good evidence that staff have undergone relevant
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 19 training. E.g. moving and handling; food hygiene; first aid; fire; elder care. To further ensure that specific needs are fully understood, staff should be provided with training on the conditions Diabetes and Parkinson’s disease. As previously required, the manager had obtained the required employment checks for the outstanding staff members. i.e. An appropriate CRB and POVA First check for one person and two job references and employment history for the newest staff. Some staff did not have proof of health clearance and this must be addressed. From the last inspection, the provider is still required to review and rewrite the home’s policies and procedures for recruiting staff. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a site visit to this service. Residents have the benefit of a home that is well run by an experienced manager who has relevant qualifications and good leadership qualities. The failure to establish a quality assurance system does not fully show how the home intends to make positive changes and monitor quality of care for residents. Overall the homes health and safety arrangements are adequate to protect the residents and staff from avoidable harm although some routine maintenance and safety checks need. If left unchecked for too long, this could put people living and working at the home at risk. EVIDENCE: Mr Sparshott, the owner/ manager has run Clifton House for many years and discussions with residents and their relatives indicated that the home was
Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 21 being managed in a positive and open way. This was also reflected by the low turnover of staff in the home and continued stability of the running of the home. Staff members spoke positively about his leadership abilities and felt well supported. The deputy manager carries out regular supervision sessions and annual appraisals for staff. Records showed that job performance is monitored and career development needs are discussed in relation to the home’s objectives and residents’ needs. In response to the last inspection, the manager has yet to develop an annual quality assurance plan for the home. Limited quality monitoring resources are in place and surveys and questionnaires have yet to be offered to the residents, their relatives and other relevant stakeholders. This must be addressed so that their views can be assessed and used to underpin the home’s quality assurance system. The opinions and views of people who use the service are important so they can influence and contribute to the home’s operation. The home was once again found to be well maintained and, generally, to promote a safe environment. The servicing and maintenance records were sampled and some were in need of updating. Weekly fire alarm tests and regular fire drills were in good order. Information about evacuation practices was documented in appropriate detail. The overall electrical safety of the home now needs to be checked, as the certificate had expired. In addition, servicing records for the hoist were out of date. Detailed risk assessments related to safe working practices within the home are in place but in need of review. Sampled files contained evidence that the majority of staff have undergone relevant health and safety training. E.g. moving and handling; food hygiene; first aid; fire and infection control. The two night staff however are still to complete fire safety and this must include participation in a fire evacuation practice. All accidents and incidents are recorded appropriately and clear safety notices are posted throughout the home. Repeated from the last inspection, the manager should undertake a regular audit of accident records to identify if any patterns are emerging concerning residents’ falls. Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 22 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 3 2 2 Clifton House (77) DS0000025770.V297053.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(c) Requirement The specific size measurements of the rooms in the home must be included in the Statement of Purpose. A copy of the Service Users Guide must be given to each resident and/or their representatives where necessary. Prospective residents must be provided with a copy at the point of admission. The manager / staff must complete a property list of each resident’s furniture and valuables as appropriate when they are admitted to the home. Risk assessments regarding the prevention of falls for residents must be reviewed as and when mobility needs change. The manager must provide more activities and recreational stimulation for residents that are in meeting with their needs and preferences. The home needs to organise more community based activities for the residents.
DS0000025770.V297053.R01.S.doc Timescale for action 31/08/06 2. OP1 5(2) 31/08/06 3. OP3 17(2) sch 4 9&10 31/07/06 4. OP7 13(4)(5) 31/07/06 5. OP12 12(1-3) 16(2) (n) 30/09/06 6. OP13 16(2) (m) 30/09/06 Clifton House (77) Version 5.2 Page 24 7. OP19 23(2)(b) (d) The registered provider must develop and maintain a written plan for the home’s maintenance and redecoration programme. (Provider to submit a copy to the Commission as now outstanding from March 2005 inspection) The provider must seek the views of residents, their family members / representatives and other interested parties to ensure that the home is meeting its aims, objectives and stated purpose. Results of these surveys must be made available in the home. (Now outstanding from March 2005 inspection) A written annual quality assurance development plan needs to be developed for the home that is based upon the views of residents and other relevant parties. (Now outstanding from March 2005 inspection) 31/08/06 8. OP33 24 31/08/06 9. OP33 24 31/08/06 10. OP38 23(4)(d,e) All staff (i.e. night staff) must receive training in fire safety with records to evidence this kept in the home. (Now outstanding from March 2005 inspection) 18(1)(a&c ) Staff must receive accredited training in the safe handling and administration of medication. (Timescale of 31/05/06 not met) 31/07/06 11. OP9 30/09/06 12. OP29 13(6)17(2 ) 19(4)(5) The home’s recruitment policy 31/08/06 and practices must be reviewed and rewritten to ensure that all necessary checks are undertaken prior to the appointment of new
DS0000025770.V297053.R01.S.doc Version 5.2 Page 25 Clifton House (77) staff. (Timescale of 30/04/06 not met) 13. OP29 17(2) 19(1)(b,c) The registered provider must ensure that all necessary written records pertaining to the staff are obtained and kept on their files i.e. proof of health clearance The registered provider must ensure that servicing checks are carried out on the home’s overall electric safety and maintenance of the hoist. Risk assessments for all safe working practices around the home need to be reviewed and updated. 31/07/06 14. OP38 12(1a) 31/07/06 15. OP38 12(1a)(2) (3) 13(4) 31/08/06 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 OP12 Good Practice Recommendations A designated activities coordinator should be allocated within the staff team so that residents are provided with structured activity sessions and entertainment. 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) The home should keep records of all social and recreational activities that residents participate in. The net curtains should be replaced in the lounge at the front of the house Staff should update their training on specific needs of some residents. I.e. Parkinson’s Disease and Diabetes.
DS0000025770.V297053.R01.S.doc Version 5.2 Page 26 2. OP38 3. 4. 5. OP13 OP19 OP30 Clifton House (77) Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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