CARE HOMES FOR OLDER PEOPLE
Clifton House (77) 77 Brighton Road Coulsdon Surrey CR5 2BE Lead Inspector
Claire Taylor Unannounced Inspection 6 & 26 October 2005 12.30p 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.V253318.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V253318.R01.S.doc Version 5.0 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 CLIFTONHOUSE@sparshott.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.V253318.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3 March 2005 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” Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over five hours and the report is based on findings from two unannounced visits made to the home. Inspection time was spent talking to the residents and staff, two visitors and the manager /owner Mr Sparshott. They are all thanked for their time and assistance. Four relatives, seven service users and one professional kindly completed a questionnaire about the home before the inspection. The Commission welcomes their comments as a valuable contribution to the inspection process. Various records, policies and care plans were examined. The premises were viewed, as were several of the residents’ bedrooms. Some concerns were identified during the first visit and as a consequence an official letter known as an “immediate requirement” was delivered to the owner on the following day. This advised that the identified concerns must be put right within 14 days or enforcement action may be taken. A second unannounced visit was undertaken on the 26 October 2005 and the registered provider had complied within the allocated timescale. What the service does well: What has improved since the last inspection?
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 6 The manager and staff have shown commitment and dedication to improving the quality of care in the home and this is reflected by the significant reduction in the number of requirements and recommendations being identified. Of the twenty-nine previous requirements (Inspection March 2005) only five remain outstanding. Four new requirements and two recommendations have been set. Future inspections can now focus on the new requirements, further good practice and maintaining standards. Residents files now contain all the necessary information required by regulation and are well organised. The needs assessment has been improved upon to ensure that an individual’s needs are more fully assessed at the point of admission. Care plans are more informative and cover each resident’s care needs in more detail. This should improve how well staff, particularly new members, know a resident’s needs and level of support required. In addition, plans of care are being reviewed at monthly intervals to ensure that any changed needs are identified and addressed more promptly. Residents have been provided with up to date contracts that outline the home’s duty of care and terms and conditions for their stay. Residents’ wishes concerning terminal care and choices and religious requirements have now been discussed and are recorded in their files. This will ensure that residents’ wishes in this area are known and observed. Risk assessments have been further developed and include fall prevention although some improvements are still needed. This has been discussed under what the home could do better. Training for staff has improved resulting in a more skilled workforce to meet the residents needs. Examples include achieved training on protection of vulnerable adults, fire safety and infection control. Supervision arrangements for staff have improved so that job performance is more closely monitored and individual training needs can be identified and met. Health and safety practices have improved in some areas. Following a fire safety inspection by the local fire authority, the owner has fully addressed the three requirements that were set. The premises has been properly risk assessed for hazards to further safeguard the well being of the people who live and work in the home. As required by regulation, any accidents or incidents that affect the well being of a resident are now reported promptly to the Commission. Notable improvements have been made to the fabric of the premises since the last inspection meaning that residents are living in a more welcoming and pleasing environment. This has included the redecoration of two bedrooms, new carpets fitted throughout the hallways, stairs and landing and a new boiler installed to improve the heating and hot water supply. There is an ongoing programme of refurbishment in the home and further work is planned including installation of double-glazed windows, new bathroom and essential repairs to the roof. The overall standard of record keeping has improved significantly and the manager continues to maintain good standards. What they could do better:
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 7 An immediate requirement was issued as the home had failed to fully address outstanding requirements concerning the vetting of staff from inspections dating back to September 2004. No CRB disclosure or POVA First check was available for five staff who work in the home. In addition to lack of a CRB check, no records, recruitment checks or documentation were available for two employees as required in the Care Homes Regulations 2001. It is important that staff are employed correctly so that residents living in the home are not put at risk and protected from people who should not be working there. A follow up visit was undertaken on the 26 October to check compliance and the registered provider had taken the required action. With regards to future recruitment, staff members must not work until all necessary checks and documentation have been put in place and the owner is in receipt of an approved CRB/ POVA check. It was identified that a review of one resident’s needs was required due to repeated episodes of falls. Although the home had taken appropriate steps to reduce the likelihood of further incidences, the placing authority (Croydon) had not undertaken a review of the person’s needs and this must be addressed. This is essential in order to evaluate whether individual needs can continue to be met. Although risk assessments covering key areas such as fall prevention are in place, they need to be more detailed to reflect the individual mobility needs of a resident. Each plan must specify the risk; possible consequences of the risk; and action required to minimise it. As further good practice, the registered provider should undertake a regular audit of accident records to identify if any patterns or trends are forming e.g. recurrent falls. While residents are provided with some opportunities for recreational and social activity, they would benefit from more active engagement in day-to-day activities. In addition, the manager should explore ways that the home could facilitate more community-based activities. This was a view shared by some of the relatives. Although significant improvements have been made to the fabric of the premises, a written plan for the overall maintenance and redecoration programme needs to be put in place. Hot water must be adjusted to a slightly lower temperature that conforms to safe limits and does not put residents at unnecessary risk. Not all staff, (i.e. night staff) are fully up to date with their training in key health and safety topics and this must be addressed. Staff must keep up to date with their training in order that they have the necessary skills and knowledge to meet the residents’ needs. Although the home uses some quality monitoring systems, a written annual plan should be drawn up for the home. Satisfaction surveys should be offered to residents, their family members and other relevant parties. Findings need to be published so that the home’s quality action plan includes their input. 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.V253318.R01.S.doc Version 5.0 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.V253318.R01.S.doc Version 5.0 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): 2, 3 and 5. Standard 6 is not applicable to this home as it does not provide intermediate care. Written contracts are provided, ensuring that residents are aware of their rights and responsibilities to live in the home and likewise, the home’s duty of care (its terms and conditions). The home has its own assessment plan to ensure that any new resident’s needs are fully assessed prior to their admission and that staff are aware of how to support them. The home demonstrates that residents’ needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: Prospective residents are invited to visit the home prior to admission, the majority of whom are referred by social services. The home has some privately funded residents. On receipt of a referral by care management or a relative, the person is invited to view the home, stay for tea and meet the other residents and staff. The home then carries out an initial assessment to ascertain whether they can meet the needs of the resident before being offered a trial period of four weeks stay. There have been three new residents admitted since the last inspection in March 2005. Their files were sampled and
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 10 each contained a detailed pre-admission assessment that had been carried out by the manager or deputy. The needs assessment has been improved upon to ensure that an individual’s needs are more fully assessed at the point of admission. They include general information about the person, details of their background, medical and social history and comprehensive details of specific care areas such as nutrition, skin care, medication and mobility. These clearly showed that the individual needs of each resident had been identified. In addition, the home completes a questionnaire to establish any personal preferences of the new resident. Records and discussion with some residents showed that the individual and his/her relatives are fully involved in the process leading up to an admission. Contact is also encouraged to ensure that relatives, who may view the home on behalf of prospective residents, are satisfied that their specific needs can be met. As previously required, details of when residents are admitted or discharged are being documented regularly. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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, 10 and 11 Residents are treated with dignity and respect. The residents’ care and health needs are identified and reviewed regularly so that they continue to be met and they are able to access care from additional healthcare services. Effective support is provided within a risk management framework although some individual plans need further development to fully safeguard individuals from potential harm. EVIDENCE: Since the last inspection, records related to the residents’ plans of care have improved significantly for which the home is commended. Five files were sampled and contained comprehensive documentation relating to each resident. Records required by the care homes regulations are now in place. The owner/ manager has developed new care plans that clearly outline a person’s individual needs and the action to be taken in order to address those needs. Plans were being reviewed on a monthly basis and care records directly related to the assessed needs identified in the care plan. This demonstrates that agreed plans of care and actions were being followed. Risk assessments covering key areas such as fall prevention are in place although some improvements are needed. Risk plans need to be expanded upon and more detailed to reflect individual mobility needs. Each risk assessment must specify
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 12 the risk; possible consequences of the risk; and action required to minimise it. Residents confirmed that staff respect their rights to privacy and dignity when receiving care and support. Likewise, care records indicate that individuals are consulted about the care that they receive. 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 and an accident book. Accident records revealed a substantial number of falls had occurred concerning one resident who had been at the home for eight months. Although the manager had taken steps to try and reduce the likelihood of further incidences, including provision of a ground floor bedroom, it was identified that a review of the resident’s needs was required. There were no records to demonstrate that the placing authority (Croydon) had undertaken a review following the trial stay period. This is important as it provides the resident and relative if appropriate, with assurance that the home can continue to meet their needs. The manager agreed to contact the placing authority to arrange an urgent review meeting / organise a reassessment of needs. As previously required, wishes concerning illness or arrangements after death are now discussed with residents and/ or their families. Any action agreed is recorded in the care plan. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. However more could be done to encourage their participation in day-to-day activities and links with the local community could be improved upon. Residents are assisted to maintain contact with family and friends. 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. EVIDENCE: From the point of admission to the home, each resident has a familiarisation profile which is a good way for staff to get to know each individual’s preferences. Residents preferred social and leisure interests are recorded in their care plans and records now being kept to show what activities are undertaken. Examples include bingo, quizzes, films and sing along sessions. There is a notice board where flyers and other events information are made available to residents. The manager advised that entertainers visit on a quarterly basis and recent events have included a musician and magician. The manager indicated that staff try, where possible, to engage service users, and help facilitate their participation in games and activities. During the inspection most of the residents were sitting in the lounge watching television and some individuals presented as under-stimulated. Pre inspection comment cards revealed that this was a view shared by some of the relatives.
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 14 The provider explained that he plans to further develop the home’s entertainment and activities programme and acknowledged that more could be done to encourage residents’ participation in day-to-day activities. E.g. the home had purchased some art and craft equipment. The former requirement is therefore repeated concerning the provision of social and leisure activities in the home. In addition, the manager should explore ways that the home could facilitate more community-based activities. Residents’ religious needs and beliefs are catered for and individuals are supported to participate in their chosen religion. There are several areas that provide adequate opportunity for residents to meet their visitors in private if they wish. Visitors are always made welcome and two spoken to during the inspection, gave positive views about the care provided for her relative and the welcoming attitude of the staff during her visits. The general care provided by staff to residents was observed to be sensitive and caring and staff consulted individuals about their preferences as appropriate. Monthly meetings are held for residents to discuss issues. The manager explained that residents are consulted about their meal choices each morning and food provisions are purchased accordingly on a daily basis. Residents confirmed that their preferences were respected and that the food provided was very appetising. Meals are home cooked and an alternative available to meet individual preferences. “Shepherd’s pie” was prepared for lunch during this inspection and appeared well presented. Drinks are provided when required and snacks can be obtained upon request. Food is served in the communal dining room, or in the resident’s own room. Special diets are catered for according to identified needs. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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 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 generally safeguard residents although the vetting of employees must be improved to ensure that people living in the home are fully protected from 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. There have been no complaints since the last inspection (March 2005). The home facilitates meetings to enable residents to bring matters of concern in order that appropriate action can be taken. There are satisfactory procedures in place for responding to suspicion or evidence of abuse, including whistle blowing and safeguarding service users financial affairs. All staff receive training on the home’s policies through the induction process. As previously required, staff have attended training on adult protection (July 2005) and certificates were available. Staff files examined indicated that the home had not undertaken all the necessary recruitment checks to ensure the protection of residents. Criminal Records Bureau checks were not available for five staff members; two of who had limited staff records that are required by the care homes regulations. This issue has been highlighted in further detail under staffing standards. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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, 21, 24, 25 and 26 Notable improvements have been made to the fabric of the premises since the last inspection meaning that residents are provided with a more welcoming, homely and pleasing environment in which to live. Residents’ bedrooms appeared comfortable and pleasantly decorated, reflecting their personal identities, and being suited to their individual needs. Overall the homes health and safety arrangements are adequate to protect residents and staff from avoidable harm although the hot water supply must be adjusted to the required temperature as a further safeguard. EVIDENCE: The registered provider has worked hard to address previous requirements concerning the redecoration and refurbishment of the premises. I.e. A new boiler has been installed and new carpets had been purchased for the hall, stairs and landing. These had been fitted by the time of the second visit to the home. Two bedrooms have been redecorated and the bathroom was in the process of being completely refurbished. The manager reported that there are plans to replace the front windows with a double-glazing type and that necessary repairs to the roof were scheduled. A written plan for the home’s
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 17 overall maintenance and redecoration programme should be put in place and the former requirement is therefore repeated. As required at the last inspection, a fire safety inspection has been carried out by the London fire and emergency planning authority. Records showed that the registered provider had addressed all of the requirements set including provision of magnetic door holders and fire risk assessment for the premises. 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. Records revealed that the hot water was running at a temperature of 49 degrees Celsius which exceeds the recommended safe limit of 43. The registered provider must therefore ensure that the hot water supply for hand basins, baths and showers is maintained at the correct temperature. The premises presented as clean and free from any offensive odours with good standards of hygiene practice well observed. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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, 29 and 30 There is a competent and well-established staff team who clearly understand the needs of the elderly people living there. Training for staff has improved resulting in a more skilled workforce to meet the residents needs. The procedures for the recruitment of staff are not robust and need improving to offer full protection to people living in the home. EVIDENCE: The staff team remain largely unchanged resulting in consistency and familiarity for the people who live there. There is a minimum of two to three staff on duty each day shift with one waking night. In the event of an emergency, additional staff who sleep on the premises are available. Rotas were examined and showed that adequate numbers of staff are in place for meeting the needs of the current residents. The registered provider’s mother works as the cook for three mornings a week and staff undertake cooking duties at other times. Out of hours, the home operates an on call system whereby the manager or deputy is readily available via mobile telephone. At the last inspection, a requirement was set that satisfactory CRB checks must be obtained for all staff. It was concerning to find that no CRB disclosure or POVA First check was available for five staff who work in the home. If staff have not been vetted correctly this could potentially place service users at risk. In addition to lack of a CRB check, no records, recruitment checks or documentation were available for two employees as required in the Care Homes Regulations 2001. Staff members must not work unsupervised until all necessary checks and documentation have been put in place and the owner is in receipt of an approved CRB/ POVA check. An immediate requirement was
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 19 issued on the 14 October 2005 with a follow up visit undertaken on the 26 October to check compliance. Evidence was seen that the registered provider had taken the required action and complied within the given timescales. Good progress has been made with regards to staff training and previous requirements addressed. Certificates showed that training undertaken since the last inspection has included infection control, adult protection and fire safety. A wide range of training opportunities are available to staff at all levels. The home has produced an induction pack that was found to be of a good standard and the files sampled evidenced a completed induction for each staff. The home keeps records which show what training courses staff have done, and when they did them. Staff supervision has improved; discussions now include career development / training needs of each staff. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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, 35 and 38 The manager has good experience, relevant professional qualifications and has created a skilled and enthusiastic workforce. Residents are therefore valued, and cared for by a competent staff team. Based on residents’ views, the home needs to develop its quality monitoring systems further to show how they intend to make positive changes and monitor quality of care. Overall, health and safety practices are well observed to ensure that residents live in a safe environment but some staff still need to attend training in key health and safety topics. EVIDENCE: The owner/ manager demonstrates competency in managing a care home, has many years experience of working with this service user group and acquired skills and knowledge through relevant training. Certificates and training records were in place. Encouraging comments about the leadership and management style of the home were received from both staff and residents. In addition, comment cards from relatives showed a confidence in the way the
Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 21 home is run. As highlighted earlier in the report, Mr Sparshott has worked hard to address previous requirements and demonstrates a commitment towards maintaining and improving standards of care in accordance with the National Minimum Standards and regulations. Some quality assurance systems are in place to ensure that the home regularly appraises its care provision. Monthly meetings are held for the residents and individuals are offered a questionnaire following their admission to the home. Following the last inspection the home was required to actively seek feedback from service users, family members and other relevant professionals to ensure that the home is meeting its aims, objectives and stated purpose. This has been partly achieved and a copy of a blank satisfaction questionnaire was in place. The manager explained that surveys were due to be offered and an annual quality assurance development plan was still to be drawn up and implemented for the home. This requirement has therefore been repeated. The home does not take any financial responsibility for any of the current residents. All of them have relatives to manage their affairs. Lockable drawers / cabinets are provided within the residents’ bedrooms for safekeeping of monies and valuables. Previous inspection requirements (March 2005) centred around health and safety practices have been addressed. I.e. Hot water temperature checks are carried out on all outlets including residents’ hand basins. A new gas boiler has been installed and the home’s services and facilities checked for compliance with water supply regulations. Events that affect the well being of a resident are being reported in accordance with regulation 37 of the Care standards act. Risk assessments related to safe working practices within the home have been completed. Records showed that the majority of staff have trained in key health and safety areas such as First Aid, Food Hygiene, infection control, Manual Handling and as previously required, fire safety. Records for two night staff however evidenced that they had only attended limited training and fire safety had not been achieved. The manager must ensure that all staff are fully up to date with their training in key topics to ensure that residents needs can be fully met and health and safety practices are adhered to. Weekly fire alarm tests and regular fire drills were being carried out. Information about evacuation practices was documented in appropriate detail. All accidents and incidents are recorded appropriately and clear safety notices are posted throughout the home. It is recommended that a regular audit of accident records be undertaken to identify if any patterns are emerging concerning falls and if particular residents are more prone to these occurrences. Certificates of worthiness for electrical appliances, fire equipment, gas / electrical safety and the passenger lift were all up to date. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 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 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES- 5 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 OP7 Regulation 14(1)(d) (2)(a) Requirement Following the admission of a new resident, the home must ensure an appropriate review meeting is held following the person’s trial stay period. Risk assessments regarding the prevention of falls for residents need to be written in more detail to further safeguard their welfare. The home provides a wider range of social and leisure activities that meet the needs and preferences of the residents. (Timescale of 30.6.05 not met) The registered provider must develop and maintain a written plan for the home’s maintenance and redecoration programme. (Timescale of 30.6.05 not met) The registered provider must ensure that the hot water supply for hand basins, baths and showers for the use of service users is maintained at a temperature of 43 degrees Celsius.
DS0000025770.V253318.R01.S.doc Timescale for action 30/11/05 2. OP7 13(4)(5) 31/12/05 3. OP12 12(1-3) 16(2) (m & n) 31/01/06 3. OP19 23(2)(b) (d) 30/11/05 4. OP25 23(2)(j) 31/10/05 Clifton House (77) Version 5.0 Page 24 5. OP29 13 (4 c) 18(1) The registered provider must ensure that all documentation required in Schedule 2 of the National Minimum Standards and regulations is obtained for the two identified staff members and retained in the home. The registered provider must ensure that staff identified at this inspection have applied for a CRB disclosure and have a POVA first check in place by 24/10/05 Immediate requirement issued, complied with by 24th October 2005 24/10/05 6. OP33 24 7. OP33 24 8. OP38 23(4)(d) (e) 9. OP38 17(2) (6a)18,19 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. (Timescale of 30.6.05 not met) 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. (Timescale of 30.6.05 not met) All staff (i.e. night staff) must receive training in fire safety with records to evidence this kept in the home. (Timescale of 31.7.05 not met) All staff (i.e. night staff) must be fully up to date with their training in key health and safety topics to ensure that residents needs can be fully met and health and safety practices are adhered to.
DS0000025770.V253318.R01.S.doc 31/12/05 31/12/05 31/12/05 31/03/06 Clifton House (77) Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP13 OP38 Good Practice Recommendations The manager should explore ways that the home could facilitate more community based activities. The registered provider should undertake a regular audit of accident records to identify if any patterns or trends are forming e.g. recurrent falls. Clifton House (77) DS0000025770.V253318.R01.S.doc Version 5.0 Page 26 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
© 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.V253318.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
