CARE HOMES FOR OLDER PEOPLE
Clifton Lodge 16-18 Clifton Road Southbourne Bournemouth Dorset BH6 3PA Lead Inspector
Marjorie Richards Unannounced 8 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Clifton Lodge Address 16-18 Clifton Road Southbourne Bournemouth Dorset BH6 3PA 01202 428598 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) cliftonlodge@hotmail.com Beechrise Limited Mrs Gail Shaw CRH PC - Care Home Only 16 Category(ies) of OP Old Age (16) registration, with number of places Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Mrs Shaw must obtain an NVQ 4 in management and care by 2005. Date of last inspection 22 February 2005 Brief Description of the Service: Clifton Lodge is a large, detached property, situated in a residential area of Southbourne in Bournemouth. Local shops are within level walking distance, with the main shopping area of Southbourne and all its amenities about half a mile away. Bus services are available a short walk from the home, providing transport to all parts of Bournemouth, Christchurch and beyond. The home is also situated fairly close to the cliff top where there are a number of pleasant walks. The property is set back from the road and approached via a short driveway with a small parking area for visitors. Additional parking is available on roads in the vicinity of the home. Clifton Lodge is registered to accommodate up to 16 older persons. The accommodation is arranged over two floors, with a through floor passenger lift to aid access between the floors. There are three double and ten single bedrooms. None of the bedrooms are equipped with en-suite facilities at the present time. The dining room and two separate lounges are situated on the ground floor, one overlooking the front garden and the other with views over the well-maintained rear garden, with its large lawn and paved patio area, surrounded by mature trees. Twenty-four hour care is provided. Laundering of personal clothing etc is carried out on the premises. Activities and occasional outings and entertainments are arranged. Meals are freshly prepared and cooked within the home. Although no choice of menu is offered, a variety of alternatives is always available to suit individual taste and preference.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours on the 8th August 2005 and was one of the two statutory inspections carried out each year. As the manager was on holiday Mr Hayward, on behalf of Beechrise Ltd., made himself available throughout the inspection, and this was appreciated. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to check if progress had been made in meeting the 11 requirements and 4 recommendations from the previous inspection. A tour of the premises took place and a variety of records and related documents were examined including the care records for three residents. Time was spent talking with seven residents, as well as Mr Hayward and the staff on duty, in order to get a real feel of what it is like to live at Clifton Lodge. What the service does well:
Information about Clifton Lodge is available for prospective residents to help them decide if the home is right for them. Pre-admission assessments are carried out to ensure that only people whose needs can be met are offered places within the home. Every resident has a care plan, which sets out in detail the individuals care needs and how these are to be met. Residents and their relatives are encouraged to contribute to care plans. Staff carry out regular reviews of care plans to ensure they are always updated as necessary. Records show that health care needs are well met. Residents say they are well cared for and treated with respect and dignity. We have very nice staff here, they are always polite and treat old people with the respect they deserve. Staff were observed throughout the inspection to be treating residents with courtesy, patience and kindness. Residents confirmed that privacy is respected, I can go to where I like when I like, and I come and go as I please. I can go to my own room whenever I wish, if I feel I want to have privacy. A range of activities is provided within the home and occasional entertainment and outings provided. A resident commented, There is plenty to do here. We can join in if we want to, but nobody minds if you prefer not to. Sometimes it is nice just to sit and talk. Residents, relatives and friends are able to
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 6 participate in some events together, such as the recent barbeques and theatre production. Meals are varied and take into account the likes and dislikes of residents. Mealtime arrangements are flexible enough to accommodate individual preferences and any social activities etc. Lunch on the day of inspection was homemade chicken and mushroom pie, with minted new potatoes, carrots and cauliflower, followed by banana custard with cream. Residents speak highly of the meals provided, e.g. We have lovely food, like a first-class hotel. I have never had a meal here that wasnt enjoyable. The home has a complaints policy in place and residents are confident that any concerns will be dealt with satisfactorily. If you are not happy about anything, you only have to say and they do their best to put it right.” No complaints have been received by the home or the Commission since the last inspection. The home has a comprehensive Adult Protection policy in place to protect service users from possible abuse. All staff have recently received Adult Protection training, to ensure a proper response to any suspicion or allegation of abuse. Clifton Lodge provides a well-maintained and comfortable environment for residents. There are spacious communal areas and a large, attractive, wellmaintained garden available to residents. Seating is provided, with a gazebo on the lawn in the summer months. Residents also enjoy sitting on the patio overlooking the garden. The home is clean and well maintained with residents commenting, The home is always kept nice and clean. My room is kept spotlessly clean. Mrs Shaw is assisted by a team of experienced staff. The needs of residents are well met by the numbers and skill mix of a staff team well trained and competent in their work. A member of staff commented, This is a very nice place to work. I have done a lot of training since I came here, which helps me do my job much better. Residents spoke highly of the staff, e.g. We have very nice staff here. Nothing is too much trouble for them. The staff are lovely here, so kind and caring. Mrs Shaw provides clear leadership and promotes a happy, relaxed atmosphere where residents are at ease. Staff said, She is a good manager. She is always there if we need her. This home is very friendly and relaxed, it is a nice place to work in. Clifton Lodge welcomes comments and ideas from residents, relatives and visitors. Questionnaires have recently been distributed to seek feedback about the homes performance. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 7 What has improved since the last inspection? What they could do better:
The home carries out pre-admission assessments to determine whether or not a prospective residents care needs can be met. Although verbal feedback is given, the outcome of these assessments is not confirmed in writing, so prospective residents are not fully assured that their care needs will be met. The way in which staff are recruited still needs some improvement. There is now a statutory requirement on providers of care to check if an individual is included on the Protection of Vulnerable Adults (POVA) list before employing new care staff. In the normal course of events, from 26 July 2004, providers of care must not employ people in care positions until satisfactory results from Criminal Records Bureau (CRB) disclosures and POVA checks have been issued. The record for a recently employed member of staff showed that the CRB disclosure was received two months after employment started and the POVA check was not documented. It is very important that proper checks are carried out in order to protect residents.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 8 Mrs Shaw is currently undertaking the National Vocational Qualification (NVQ) Level 4 in management, which she hopes to complete before the end of 2005. When this has been achieved, Standard 31 (and a condition of registration) will be fully met. More attention is needed to carrying out staff fire training and fire drills at the required intervals, to ensure resident safety. 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 Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 1 and 3 Information provided about Clifton Lodge and a thorough admissions procedure allows prospective residents to make informed decisions about admission to the home and ensures that only those whose needs can be met are offered places there. However, the outcome of pre-admission assessments is not confirmed in writing, so prospective residents are not fully assured that their care needs will be met. EVIDENCE: The Statement of Purpose and Service User Guide are well laid out, easy to read and contain all of the information required about Clifton Lodge and its facilities. These documents give a good indication of what a resident can expect from the home and are given to prospective residents and/or their representatives when they are at the point of selecting a care home. A copy is also available in each residents bedroom within the home. In addition, information is available in the entrance hall, which includes a copy of the latest inspection report. Clifton Lodge also has an e-mail address where further information can be requested at any time.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 11 Individual care records are kept for each resident and two of these for recently admitted individuals were examined. Both showed that, prior to moving to the home, care needs had been assessed by the homes manager. However, at present, the outcome of such assessments is not confirmed in writing, so prospective residents are not fully assured that their care needs will be met. The information contained in pre-admission assessments and also any assessment supplied by Social Services, is then used to draw up a detailed plan of care. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 7, 8 and 10 Clifton Lodge has a detailed care planning system in place, which ensures that staff have sufficient information to meet needs of residents. Good support from community health professionals helps to ensure that the health needs of residents are well met. Residents are treated with respect and their privacy and dignity is promoted at all times. EVIDENCE: All three of the care plans examined were clearly set out, detailing the particular health and personal care needs of each resident, the aims and objectives and the staff assistance necessary to ensure these are met. Where assessments on admission have identified needs, these have been dealt with promptly, e.g., the involvement of a chiropodist and dentist. Information about social care needs is recorded and a social interaction care plan provided. Records demonstrate that care plans are reviewed monthly or more often where necessary, to ensure they reflect changing needs and objectives and are always fully up-to-date. Daily care notes support and evidence the delivery of care to residents. These are well detailed and give a good picture of the care provided, as well as visits by community health professionals and relatives etc. Residents and their relatives are encouraged to contribute to care plans.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 13 Records demonstrate that residents have access to GPs, district nurses, dentists, opticians, chiropodists, etc and attend for hospital appointments as necessary. Residents confirmed this during the inspection. Risk assessments are in place and appropriate steps are taken to minimise any risks identified. Throughout the inspection, staff were observed to be treating residents with courtesy, kindness and respect. Residents commented, The staff here are very good. They can share a laugh and a joke with us, but they are never disrespectful. We have very nice staff here, they are always polite and treat old people with the respect they deserve. Toileting activities were observed to be carried out discreetly and in a manner which maintained privacy and dignity. Records show that gender sensitive care is offered, with each residents preferences for male or female staff to look after them being recorded. Residents confirmed that they were asked by what name they wished to be addressed and staff respected their wishes. Privacy is also respected, I can go to where I like when I like, and I come and go as I please. I can go to my own room whenever I wish, if I feel I want to have privacy. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 A range of activities and events provides variation and interest for residents and meets their needs. Residents are encouraged to maintain contact with family and friends and the wider community. Clifton Lodge serves a balanced and varied selection of food that meets residents’ tastes and special dietary needs within pleasant surroundings. EVIDENCE: The Activities Record shows that residents have access to a wide variety of activities within the home. These include skittles, dominoes, armchair hockey, gentle exercise to music, sing-alongs, ball games, reminiscence, board games such as snakes and ladders and going for walks. A resident recently suggested playing darts and a magnetic dartboard has just been purchased. TV, video player and music centre are provided in the main lounge and newspapers, magazines, books and a piano are available in the quiet lounge. Background music is played during mealtimes in the dining room, at the request of residents. Occasional outings are arranged and entertainment or other events are organised on a monthly basis. Residents mentioned All the Nice Girls Love a Sailor which was performed in the home during July by a travelling theatre company. Another show is booked for Christmas. Two barbecues have been
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 15 held recently and much enjoyed in spite of inclement weather. A further barbecue is planned in August and residents are able to invite their relatives and friends to these events. Residents confirmed they are happy with the current arrangements. One resident commented, There is plenty to do here. We can join in if we want to, but nobody minds if you prefer not to. Sometimes it is nice just to sit and talk. One resident attends a local church on a regular basis. Arrangements are made to assist individual residents in attending church if they so wish, or for clergy to visit them at Clifton Lodge. Discussions with residents confirm that they are able to come and go as they please and receive visitors whenever they wish, with no restrictions placed upon them. Several residents are able to go out of the home alone and others with their families/friends or with staff. Members of the wider community visit the home on a regular basis, e.g. the hairdresser, chiropodist and entertainers. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. Residents and staff said all visitors are offered refreshments and are made to feel welcome on arrival at Clifton Lodge. Information about visiting and maintaining contact with family and friends is available in the Statement of Purpose. A cordless telephone is provided for residents and several also have their own telephones, so can easily maintain family and community links. Lunch on the day of inspection was homemade chicken and mushroom pie, with minted new potatoes, carrots and cauliflower, followed by banana custard with cream. Alternatives such as omelettes and salads are always available to suit individual taste and preference. On Sundays, a glass of sherry or wine is served with lunch. Residents may choose to eat their meals in the dining room, in their bedrooms or outside in the garden, (weather permitting). Lunch in the main dining room was observed to be served in a relaxed, unhurried atmosphere with discreet staff assistance provided wherever necessary. Mealtimes can be flexible to fit in with care needs, appointments etc. The menu shows that residents enjoy a healthy, well-balanced diet. Fresh fruit and vegetables are used wherever possible and special diets can be catered for. The home has a good supply of foodstocks, all appropriately stored. Residents commented, I enjoy my food here and look forward to mealtimes. The chef is excellent. If we dont like what is on the menu, he will always prepare something different for us. He is very obliging We have lovely food, like a first-class hotel. I have never had a meal here that wasnt enjoyable. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 16 and 18 A system is in place for dealing with any complaints. Residents are confident that complaints would be listened to and dealt with appropriately. The home has a comprehensive Adult Protection policy in place to ensure residents are protected from possible abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the Service User Guide provided to all residents in their bedrooms. A copy of the complaints policy is also available to visitors in the entrance hall. The complaints record confirms that no complaints have been received by the home or the Commission since the last inspection. Residents said they would feel able to voice a complaint if necessary and felt that their concerns would be taken seriously, and acted upon. Comments included: If you are not happy about anything, you only have to say and they do their best to put it right.” I have absolutely no complaints about this home. I am very happy here.” Gail (manager) is always saying we should tell her if we are unhappy about anything. She wants us to be happy here. The home has a comprehensive Adult Protection policy in place to protect service users from possible abuse. This makes reference to the Department of Health No Secrets document, which is also available to staff. All staff have recently received Adult Protection training, to ensure a proper response to any suspicion or allegation of abuse.
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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 standard(s) 19, 20, 24 and 26 Continuous investment in the upkeep of the home results in a well-maintained and comfortable environment for residents, where standards are constantly improving. Although the home endeavours to provide a safe environment for residents, more attention must be paid to carrying out staff fire training and fire drills at the required intervals, to ensure resident safety. The home provides access to a variety of communal areas, including attractive gardens. Bedrooms are comfortably furnished and individually personalised to suit their occupants. Clifton Lodge is clean with no unpleasant smells, making daily life more pleasant for all in the home. EVIDENCE: Maintenance records show that continual work is carried out to keep the home and grounds in good condition. Since the last inspection, the walls of the dining room have been redecorated. The kitchen has also been redecorated and an extractor fan is to be fitted. At present, a portable ramp is available to allow access to the garden areas for wheelchair users via the front door.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 18 Mr Hayward is planning to improve access to the garden from the rear of the home, as residents currently have to negotiate some steps. He is also in the process of creating a permanent ramped access to the front door. A tour of the building revealed that the building is well maintained. Documentary evidence also shows a regular maintenance programme is in place and equipment, such as hoists and the lift, are regularly serviced. The fire records show appropriate checks and regular servicing being carried out on the fire warning system, emergency lighting and fire fighting equipment. An updated fire risk assessment has just been completed. However, although staff receive fire training, there is a need to ensure that this is carried out at the appropriate intervals for new staff and night staff and is fully recorded. Similarly, a detailed record must be kept of all fire drills. Written evidence did not substantiate that fire drills were taking place at the required intervals. An Immediate Requirement Notice was not issued as Mr Hayward demonstrated that fire drills and staff fire training were now organised to take place shortly with an external trainer. All radiators and pipework are guarded to help ensure service user safety. Pre-set valves are in place at baths to ensure hot water temperatures are regulated. Hot water at baths was checked and found to be close to 43C, the recommended temperature to prevent any risk of scalding. For health and safety reasons, the home has a no smoking policy for all service users, visitors and staff. Clifton Lodge has an attractive, homely television lounge at the front of the home with views of the road and passers by, a separate quiet lounge and a dining room at the rear of the home with views of the garden. Newspapers, magazines and books are available and there is a piano in the quiet lounge. The spacious rear garden is laid mainly to lawn, with mature trees, shrubs and flowers. There is a patio area and a portable gazebo, which is erected on the lawn during the summer months when weather permits. Garden furniture is available and residents confirm that they enjoy using the garden. Discussion with residents and tour of the building demonstrates that bedrooms are comfortably furnished and personalised to varying degrees. Residents commented, “I am very happy with my room, I am very comfortable here.” I am very fond of my room. I brought a number of my things with me, so it is more like home. Clifton Lodge is clean and there are no unpleasant smells, making life within the home more pleasurable for residents, staff and visitors. Suitable facilities and procedures are in place in respect of laundry. Residents commented, The home is always kept nice and clean. My room is kept spotlessly clean. The laundry service is very good.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The numbers and skill mix of staff are sufficient to meet the present care needs of residents. Practices in relation to recruitment of staff need improvement to ensure appropriate checks are carried out and fully recorded, for the protection of residents. The home acknowledges the importance of staff training and ensures that staff are well trained and competent to do their jobs. EVIDENCE: Mrs Shaw heads a team of staff who are experienced in caring for people. On the day of inspection the following care staff were on duty: 08.00 - 14.00 2 care assistants 14.00 - 20.00 2 care assistants 20.00 - 08.00 1 wakeful night care assistant. 20.00 - 08.00 1 sleep-in night care assistant (wakeful from 20.00 - 23.00 and 06.00 - 08.00) In addition, a chef and housekeeping staff are employed. The home is actively seeking to recruit further care staff at the present time. An equal opportunities policy underpins the practice of the home. There is now a statutory requirement on providers of care to check if an individual is included on the POVA (Protection of Vulnerable Adults) list before employing new care staff. In the normal course of events, from 26 July 2004, providers of care must not employ people in care positions until satisfactory results from Criminal Records Bureau (CRB) disclosures and POVA checks have
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 20 been issued. The record for a recently employed member of staff showed that a CRB disclosure had been received two months after employment started. (The manager later explained that a POVAfirst check had been carried out by the agency supplying the employee, but this was not documented.) The home takes staff training seriously as a means of improving the standard of care provided and ensuring residents safety. Training records and discussions with staff confirm that recent training courses have included adult protection, moving and handling, first aid, basic food hygiene, health and safety, infection control and the administration of medicines. A member of staff commented, This is a very nice place to work. I have done a lot of training since I came here, which helps me do my job much better. Residents speak highly of all the staff at Clifton Lodge. The following comments are typical; We have very nice staff here. Nothing is too much trouble for them. The staff are wonderful, all of them are very attentive. They make a lovely cup of tea, just how I like it and whenever I want it. The staff are lovely here, so kind and caring. Although not assessed on this occasion, Mr Hayward said that arrangements for formal staff supervision had now been implemented and all care staff would be receiving supervision every two months. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 35 The registered manager is experienced in care and provides clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews its performance and actively seeks the views of residents, staff and relatives to ensure the home is run in the best interests of residents. Residents are assured of sound management of their financial interests. EVIDENCE: Mrs Shaw is currently undertaking the National Vocational Qualification (NVQ) Level 4 in management, which she hopes to complete before the end of 2005. When this has been achieved, this Standard (and a condition of registration) will be fully met.
Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 22 Mrs Shaw provides clear leadership and promotes a happy, relaxed atmosphere where residents are at ease. Staff said, She is a good manager. She is always there if we need her. This home is very friendly and relaxed, it is a nice place to work in. The home operates an Open door policy, ensuring that anyone can come to the office and speak with Mrs Shaw (or Mr Hayward when present) at any time. Working relationships between management, staff and residents were directly and indirectly observed throughout the course of the inspection. They appear open, friendly, yet professional, contributing to a welcoming and relaxed atmosphere, which is beneficial to all in the home. Mr Hayward, the Responsible Individual on behalf of Beechrise Ltd. makes the required unannounced visits to the home at least monthly, to check on the standard of care provided. He prepares a written report on the conduct of the home and a copy of this is forwarded to the Commission. Mr Hayward says he feels it is vital to have regular contact with residents in order to make sure that the home is meeting their needs and operating in their best interests. Residents confirm that Mrs Shaw spends time talking with them every day to see how they are and to obtain their views. Quality Assurance questionnaires have recently been sent out to visitors to the home and a further questionnaire is planned shortly for residents and relatives. Mr Hayward confirms that, in order to protect residents, it is the policy of the home not to have any involvement in their personal finances. Therefore, all residents who are unable or do not wish to handle their own affairs, have a relative or other representative to deal with their finances etc. This means that, where necessary, the home pays for services such as chiropody and hairdressing and a record is maintained. This amount is then invoiced to residents, relatives or representatives for payment each quarter. Residents are encouraged not to bring valuables into the home and no possessions are being held for safekeeping at the present time. Information about advocacy services is available to residents should they wish to seek independent advice. In order to protect residents, policies are in place precluding staff acceptance of gifts or involvement in residents wills. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4
COMPLAINTS AND PROTECTION 2 3 x x x 3 x 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 Standard No 16 17 18 Score 3 x 3 2 3 3 x 3 x x x Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14(1)(d) Requirement Timescale for action 31/10/05 2. 29 19 3. 31 9(2) (b) (i) 4. 19 and 38 17 (2) Schedule 4 The registered person must confirm in writing to the service user that, having regard to the pre-admission assessment, the care home is able to meet his/her care needs in respect of health and welfare. The registered person must 31/10/05 operate a thorough recruitment procedure ensuring the protection of service users. It is a requirement that Mrs 31/12/05 Shaw must obtain a National Vocational Qualification level 4 in management and care by 2005. (Previous timescale of 2005 still current.) It is a requirement that clear and 31/10/05 detailed records are kept of staff fire training and fire drills to fully demonstrate compliance. (Previous timescale of 1/5/05 not met.) Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 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. Refer to Standard 28 Good Practice Recommendations It is recommended that a minimum ratio of 50 trained members of care staff at NVQ level 2 or equivalent is achieved by 2005. Repeated. Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clifton Lodge D55 S50468 Clifton Lodge V242425 080805 Stage 4.doc Version 1.40 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!
