Inspection on 01/08/05 for Clifton Manor

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clifton Manor 13/10/08

Clifton Manor 15/10/07

Clifton Manor 19/02/07

Clifton Manor 20/05/05

Clifton Manor 21/02/05

Clifton Manor 02/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Clifton Manor 67 Manor Road Wallington Surrey SM6 0DE Lead Inspector Barry Khabbazi Service User Inspection & Announced inspection 1 & 2 August 2005 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clifton Manor Address 67 Manor Road, Wallington, Surrey, SM6 0DE 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) 020 8669 5305 020 8669 3060 Mr Sheik Mohamedally & Mrs Patricia Mohamedally Mrs Jacqueline Lehane Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21 February 2005 Brief Description of the Service: Clifton Manor is a double fronted, detached property that is registered to provide care to a maximum of eight people with learning disabilities. Mr and Mrs Mohamedally are the registered providers, the home having a manager and staff team to run the service on their behalf. The home is situated in Wallington - between Sutton and Croydon - on a main road close to the local town’s shops, pubs, churches, and public transport links - both by bus and train (Wallington railway station is nearby). The home provides care for seven adults with severe to modarate learning disabilitys; some of the residents may also have moderate / medium levels of challenging behaviour. Each resident has a single bedroom, with bathrooms including a whirlpool bath - showers and toilets sited throughout the ground and first floors. There is a staff / conference / meeting room and another shower room / toilet on the second floor. As well as the lounge, dining room and office room. There is a garden to the rear of the premises, which has a patio area and also a sturdy wooden framed garden chair swing. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report refers to a pilot service user inspection on the 1/8/2005 and the inspector’s announced inspection of the 2/8/2005. This pilot is occurring in all three homes of a group owned by the service provider. The information gathered from the service users is recorded only in this summary below, but is referenced as supporting information throughout the report. The information from the lead inspector’s inspection is recorded throughout this report. The inspector was able to speak to all the residents on this occasion. During this inspection the manager was interviewed and records, care plans and the building were examined. The service users inspection process: Two service users volunteered to be involved in this pilot service user led inspection. A pictorial inspection guide was devised and training in their inspection process was provided to the two service users concerned. A more accessible form of feedback to the service users will also be devised following this report. The two service users that volunteered for this process spilt into two groups. Each group comprised of one of the inspecting service users, a support worker, the lead inspector for the home, and three other service users. The inspecting service users then asked their group of service users set questions covering a group of National Minimum Standards. This was supported by a pictorial question guide and the support worker present. The main purpose of this pilot was to develop ways of involving the service users more. The information gathered from the service users was therefore seen as an additional bonus and methods to improve the accuracy of responses will therefore need to be developed further. The conclusions below are based on verbal responses, pointing to pictures, and interpretation of facial expressions and body language and therefore may not fully reflect all the views of the service users completely accurately. The service users’ inspection conclusions: 1 out of 8 service users chose not to be involved in the process. 4 out of 8 service users liked the home’s meetings. 2 out of 8 service users did not like the home’s meetings. 2 out of 8 service users did not fully respond to this question. 5 out of 8 0 out of 8 3 out of 8 Individual service users liked the home’s activities. service users did not like the home’s activities. service users did not fully respond to this question. requests for more sewing and swimming were made. G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 6 Clifton Manor Indications that activities were also enjoyed at the home’s day centre were made. 5 0 3 2 out of 8 service users liked the home’s outings. out of 8 service users did not like the home’s outings. out of 8 service users did not fully respond to this question. service users indicated that they were interested in the fun fair. 4 out of 8 service users liked the home’s holidays. 2 out of 8 service users did not like the home’s holidays. 2 out of 8 service users did not fully respond to this question. 5 out of 8 service users liked the home’s food. 1 out of 8 service users did not like the home’s food. 2 out of 8 service users did not fully respond to this question. Preferences of types of food were also expressed here. 5 out of 8 service users liked their bedrooms. 0 out of 8 service users did not like their bedrooms. 3 out of 8 service users did not fully respond to this question. 5 out of 8 service users said the home was clean. 1 out of 8 service users did not think the home was clean. 2 out of 8 service users did not fully respond to this question. Additional information; I Like the garden, I Like the lounge, I like cleaning. I like sitting in lounge and dining room. I don’t like baths. The home’s feedback regarding the service users’ inspection pilot: 1, It was good that the inspector had and took time to get to know the service users better and did not rush them. 2, Although training in the process occurred, it was still difficult for the service users as most of them communicate through their body language. 3, It was a good thing that the process was flexible enough to allow the service users to express what they liked as opposed to only answering the questions directly. 4, It would be better next time if questions could be more open to facilitate more information being gathered from those service users who can express themselves better. 5, Some of the questions were difficult for some service users. 6, The manager’s view was that there was a very relaxed atmosphere among the service users and they were very happy to show the inspector around the home. 7, The manager and support workers think that it is a good idea to involve the service users more in the inspection and preferred this style of inspection. The inspector’s conclusions regarding the service users inspection pilot: 1, The inspector agrees with the home’s feedback above. 2, The service users conducting the inspection and those engaged in it both appeared to enjoy the exercise, as did the inspector. 3, The inspector appreciated how this kind of inspection allowed him to get to know the service users better. This has improved communication for future inspection. 4, The service users appeared to be used to and comfortable with this kind of consultation, which indicated that consultation occurred regularly at this home. 5, Where service users could directly answer questions responses were generally positive. 6, That all the service users have something to contribute to the inspection process regardless of ability. This was also the case even where exercising the choice not to participate. 7, This was a good starting point for developing service user involvement. {Further details of the process and conclusions of the service user inspection pilot can be obtained via the lead inspector} What the service does well: Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 7 Service user inclusion, involvement and service user consultation are areas of good practice for this home, and the service users’ familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. This is reflected by Standard 8 – ‘service user consultation and participation in the running of the home’, being exceeded. This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. Standard 25, which refers to minimum room sizes and a maximum of 20 percent of places in double rooms is numerically exceeded in both areas. All rooms exceed the minimum 10 sq m required. It is expected that communal room sizes will also exceed the minimum size and the manager presenting this information at the next inspection could enable this to be also recorded as an exceeded standard. What has improved since the last inspection? Packets of food products, once opened, are now stored in sealed containers to reduce the risk of contamination/infestation. Fridge temperatures are now regularly recorded which should reduce the risk of infection from contaminated food for residents. All residents now have a statement of their care plan and daily file, to ensure that work with the individual is focused and appropriate and ‘inspired’ by that individual’s aims and goals. The home’s Abuse Policy has had further clarification to ensure that staff understand the procedures fully. Staff have now signed against an index of current policies and procedures to confirm that they have received, read, understood and will abide by the home’s declared expected practices. Routine checks (minimally monthly) and the maintenance of any wheelchairs used at the home are now occurring and are recorded to show adequate precautions are taken to ensure the safety of users. Wedges used to hold doors open (such as previously seen in bedrooms and the office) have now been removed. This will allow fire doors to protect the residents from fire. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 8 All fire extinguishers are now fixed to the wall safely and not left on the floor. This will ensure that the extinguishers do not become damaged, are available when required and do not present a tripping hazard. Following service user consultation, the home has purchased a new basket ball net and a gazebo. What they could do better: 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 Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2. Prospective service users needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: The newest service user’s file was examined and this contained the care management assessment and care plan as required by this Standard. In addition the home has completed its own assessment of need. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, and 9. Plans of care contain originally assessed needs and are updated regularly. This will help staff know all a resident’s needs and how to meet them. Although the service users’ assessed needs are generally well met by this home, how the home meets residents’ needs is not fully recorded. This could affect the home’s ability to meet, and show how it has met, all a service users’ known and changing needs. Service users are consulted on all aspects of life in the home and these views are implemented where appropriate. To facilitate this information regarding the home’s policies, activities and services, are produced in more accessible formats including pictorial versions. Risk assessments contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the service users. EVIDENCE: The 2004/5 announced inspection report recorded under Standard 6 that ‘the home’s care planning documents were comprehensive, but set out in a concise manner how most of a service user’s needs are to be met. The service users Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 12 each have an action plan generated from the comprehensive assessment completed by the care manager. Risk assessments were also present on the files sampled to monitor, among other things, challenging behaviour. Service users have a key worker who also completes a monthly retrospective review report on the service user’s progress; the information is used at the service user’s annual review to give an ‘overview’ of the individual’s goals and achievements. This was still the case at this inspection. The daily notes were examined the last inspection. There were many dates without entries and records did not demonstrate how the care plan was met on that day. For example, one file examined for resident S.O. for the first 20 days in May had entries for only 11 days out of a required 20 days. There had been some improvement by this inspection but frequency and content still need to be improved. Although this affects this Standard, a recommendation regarding this remains under Standard 41 and will not be repeated here. The care plans could be improved with references to other documents recorded in it, for example, references under activities to the activity list. The following suggestion only at this time is made: Care plans could be further improved with references to other connected documents recorded within in it. The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through, accessible documentation including pictorial versions, regular house meetings and individual discussions with their key workers, and involvement in the annual development plan for the home. See also the service user inspection pilot recorded in the summery for further supporting evidence. Service user inclusion and involvement is an area of good practice for this home, and the service users’ familiarity with involvement in the home was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. Choices are also respected and actioned as evidenced by the new gazebo and basket ball net that service users wanted now being present at the home. This is reflected by Standard 8 being exceeded. Risk assessments are in place for all areas where restraints or restrictions of liberty are pre-planned. These contain all the information required under this Standard, including what training or other options have been explored before a restraint or restriction of liberty is applied. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15, 16, and 17. Service users’ have the opportunity for self-development, and are part of the local community. Service users’ are offered a healthy diet and have choices in meals offered. The safe storage of the residents’ food is being maintained to a satisfactory standard. Service users’ are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The daily routines and house rules promote service users’ rights, to ensure equality and that all rights are enjoyed by all residents. EVIDENCE: Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 14 Evidence was provided of service users attending collage to continue education. Independent living training occurs at the home and day centre, and is supported by staff and key workers. The home provides its own day centre in Thornton Heath, which service users attend. The activities at the home’s day centre were previously inspected and included Adult Education and independent living skills. Service users are supported to attend community activities that they have shown an interest in. This includes outings to pubs, attending college and using the local hairdresser, walks, shopping and eating out. The home is within easy walking distance of local bus and train links. The home also has its own mini bus, which is used for outings to the coast and country pubs. The home has a good relationship with their neighbours and they are invited in for any social events such as the Christmas party or summer barbeque. The service users are registered to vote and are given the choice of whether or not to vote on election day. There is a file of information regarding local activities held at the home. The staff team supports the service users to maintain links with their families and friends through a flexible visiting policy, and by ensuring relatives are always invited to reviews and social events where appropriate. Some of the service users have regular overnight stays at their parents’ home. Visitors can be seen in communal areas or the service users room. Visitors can also stay at the home overnight where a room is provided. Service users have the opportunity to make friends who do not necessarily have their disability, through community use. Staff have information and health training to support service users in making appropriate and informed decisions where they wish to develop close relationships, and they would ensure that this was mutually welcomed. Evidence was provided to confirm that where this is not welcomed or appropriate, staff do take appropriate action to protect the service user. Service users’ do not receive all the paid holidays they are entitled to. The home has approached the placing authorities for this but the placing authorities has not provided this yet. Although the following recommendation is technically required it is recognised that it refers more to the placing authority than the home and will therefore not appear in the section ‘what the home could do better’: Each resident should be offered a seven-day holiday paid for by the placing authority as a part of the contracted price. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 15 The daily routines and house rules do generally promote independence and choice. See also the service user inspection pilot recorded in the summary for further supporting evidence. Meals, for example, can be taken where and when service users want, and they go to bed and get up when they want. This is done within the context of enabling service users to attend appointments and other commitments. Staff were observed to talk to the service users in a respectful manner and knocked before entering their rooms. The manager was previously observed to do this even when no one else was in the building through habit. The service users choose the menus with the assistance of the staff team. The menu is varied and included alternatives if service users wanted something different. Breakfast consists of cereals, toast and a cooked breakfast is available at the weekend. The service users usually have a packed lunch as they attend the home’s day centre but on certain days they engage in cooking meals at the day centre as a part of independent living training. Supper is the main cooked meal of the day and evening snacks and drinks are provided. Additional snacks and drinks are available at any time. The menu at the home has been to be put into a pictorial format suitable for the people living at the home. The 2004/5 inspection report recorded under Standard 17 that ‘this Standard was found to be unmet as the inspector’s tour of the kitchen identified a number of requirements with regard to food hygiene practices.’ The following requirement was then set: Packets of food products, once opened, must be kept in sealed containers to avoid the risk of contamination/infestation (17.1 & 42.1-3). By the time of this inspection the practice of storing opened food in sealed containers had been implemented and this requirement is now met. At the last inspection, the records of the fridge temperatures were also checked. For the first 20 days in May there were only recorded temperatures for 8 out of a required 20 days. This was of additional concern as the home’s own fridge policy states that temperature recording should occur daily. The following requirement was set at that time: Fridge temperatures must be checked on a daily basis. Daily records of fridge temperatures were available by the time of this inspection and this requirement is therefore currently met. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, and 20. Service users’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’ medication is also well managed to ensure maximised good health. EVIDENCE: There are no service users with sensory or physical impairments significantly affecting mobility and/ or requiring aids and adaptations such as hoists to be present in the home. The home does not currently provide places for, and is not suitable for, people with a secondary physical or sensory impairment significantly affecting mobility. Encouragement, guidance and support with personal care is provided to service users where required. The service user group all need assistance with their personal care and where possible a person of the same sex offers this support. Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. The home has been promoting regular health checks. Service users are supported to attend outpatient appointments and other medical appointments Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 17 as required. All service users have regular medical reviews, which are conducted in private in their own rooms. The continence advisor has visited and access to opticians, dentists and audiologists was demonstrated. District nurses and other healthcare professionals attend when required. Evidence was seen of regular and accurate monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept on the daily record sheets and monthly reports. The service users’ health is discussed at the annual review. It is part of the key worker role to monitor the health needs of the service user. None of the current service users are able to self medicate. However, procedures and a lockable space in service users’ rooms are present to facilitate self-medication if appropriate. Most of the service users have been assessed as unable to give their consent to medication. This is written into their care plan and consent is obtained from their families. Medication and M.A.R. sheets are kept in a locked cabinet. Individual blister packs are used for tablets instead of bottles for easy identification and monitoring. The home has a policy for the administration of medication, staff who administer medication have been trained and are required to check the possible side effects of any medication in the British National Formulary. The manager carries out their own spot checks to ensure the procedure is adhered to. There were no records of the service users preferences, for how their support with personal care is carried out. This is required under Standard 18.2 and the following recommendation is now set to address this: The service users’ preferences for how their support with personal care is carried out should be recorded. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. On the whole this home manages complaints well and there had been no complaints since the last inspection. The home’s policies and procedures relevant to this Standard currently facilitate protecting residents from abuse. EVIDENCE: There had been no official complaints since the last inspection. The home has a complaints procedure that meets all the elements of this Standard including a minimum response time of less than 28 days, details of the Commission and this is also available in more accessible pictorial formats. The home does have a copies of the placing authority’s adult protection procedures. The Restraint Policy has been developed to cover all the areas required. This also includes appropriate recording mechanisms. The home has a Whistle Blowing Policy, a Gifts Policy and the Wills Policy does preclude staff from being involved in the making of, or benefiting from residents wills. The last inspection report contained a recommendation under Standard 23 for the home’s Abuse Policy to speak of the situation where, for a service user’s and staff member’s safety, a situation of ‘suspension from work - without prejudice’ may well be temporarily invoked (23.2). This had occurred by the time of this inspection with the required information being included in the Abuse Policy. In addition a more accessible version had been produced for the service users. The recommendation is therefore now met. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 19 Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, and 30. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. Bedrooms are suitable and all exceeded the minimum 10 sq m required. The home is hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: The home is a large double fronted, detached house with eight bedrooms and is in keeping with the local community. At the time of the inspection the premises were decorated in an appropriate style and reasonably maintained with maintenance records kept. The grounds were observed to be well kept and accessible to the current service user group. There was suitable lighting and ventilation. Doors are sufficiently wide. Automatic ‘Magnetic’ fire door closing devises are present on fire doors. The furniture is domestic in nature, flame retardant. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 21 Standard 25, which refers to minimum room sizes and a maximum of 20 percent of places in double rooms is numerically exceeded in both areas. All rooms exceed the minimum 10 sq m required. The building was clean and tidy and was generally free of offensive odours. See also the service user inspection pilot recorded in the summary for further supporting evidence. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. There are Control Of Substances Hazardous to Health data sheets in their own file. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. The laundry room was positioned so that laundry does not need to be carried through the kitchen. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, and 36. This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. The home’s recruitment procedures protect the residents through vigorous staff vetting. Although service users needs are well met by suitably experienced staff, all staff are not fully trained. Service users do benefit from a well supervised staff team. EVIDENCE: The following good practice was identified: This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks have not been applied for and disclaimers held on file. Volunteers are not used at this home. The staff files sampled contained Criminal Record Bureau checks, interview notes, statements of terms and conditions, identification checks, two written references and staff photographs. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 23 The manager is reminded that CRB checks will need to be updated every three years. Training and development is linked into the home’s aims and service users’ needs. All staff receive at least five days training pro rata per year. This home has received an ‘Investors in People’ award. The staff induction programme is devised from the Training Organisation for Personal Social Services standards booklet. Staff have a week’s internal induction before moving on to structured ‘LADAF’ 6 week induction and 6 month foundation training programme. The last inspection report contained the following recommendation under this group of Standards: Staff should be required to sign against an index of current policies and procedures (and future documents as they come on stream) to confirm that they have received, read, understood and will abide by the home’s declared expected practices (31). This had been reinstated by the time of this inspection and this recommendation in therefore curently met. The last inspection report also contained the following recommendation under this group of Standards: At least 50 of care staff should be qualified at NVQ Level 2 by 2005 (32.6). There is currently around 33 of staff with the required qualification. However there are almost 80 of staff with the required qualification or currently on the course. This recommendation will remain untill fully met. The staff team receive regular supervision, which is recorded on their files. Staff supervision includes translation of the home’s philosophy into work, monitoring work, support and professional guidance and identification of training needs, as required under Standard 36.4. All staff have an annual appraisal where their training needs are discussed. The home has regular staff meetings, which are recorded. There is also a shift evaluation meeting where staff are briefed and receive feedback. The manager explained that they have an “open door” approach whereby staff can speak to the senior on duty if they are unclear about any thing. Copies of the home’s grievance and disciplinary procedures are given to staff when they start and procedures required for dealing with physical aggression are in place. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41, and 42 The home’s quality assurance system involves the residents and relatives, and provides feedback to them, to allow them to be fully involved in improvements and measure improvements in the home for themselves. Although the home generally promotes the health and safety of the residents, some practices remain that could place their health and safety at risk. EVIDENCE: Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 25 There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, provider inspection visits, user satisfaction surveys, and an annual development plan open to service users through an annual quality assurance meeting. The user satisfaction surveys that have been devised are accessible and include written questions and pictorial cues. This has now been put into practice and has resulted in service user suggestions for improvement in quality being implemented. For example the home has purchased a new basket ball net and a gazebo. Service user inclusion, involvement and service user consultation are areas of good practice for this home, and the service users familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. This is reflected by Standard 8 – ‘service user consultation and participation in the running of the home’ being exceeded and Standard 38 ‘an open and inclusive atmosphere’, being identified as an area of good practice. See also the service user inspection pilot recorded in the summary for further supporting evidence. The last inspection report contained 2 requirements and 2 recommendations under this group of Standards. 1, All service users must have a statement of their care plan - even if interim on the daily file, to ensure that work with the individual is focused, appropriate and ‘inspired’ by that individual’s aims and goals (41.1 3). This had occurred by the time of this inspection and an additional copy is now also held in the daily file to assist with handovers. This requirement is now therefore met. 2,Routine checks (minimally monthly) and the maintenance of any wheelchairs used at the home must be recorded to show adequate precautions are taken to ensure the safety of users (42.4). This had also occurred by the time of this inspection with regular maintenance records available for inspection. This requirement is now therefore met. The last inspection report contained the following recommendation: It is strongly recommended that records concerning service users are restored to minimally daily entries - this tied in with a focus on specific care plan aims and goals (41.1 3). There had been some improvement by this inspection but frequency and content still need to be improved. The recommendation will remain in force until fully met. The last inspection report contained the following recommendation: The registered manager should be qualified to NVQ Level 4 in Management and Care by 2005 (37.2). Although the manager is currently awaiting verification Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 26 this has not occurred yet. The recommendation will remain in force until fully met. The last inspection report contained the following requirement under Standard 48; ‘Wedges used to hold doors open (such as seen in bedrooms) must be avoided at all costs - with approved devices being used when necessary’ By the time of this inspection all wedges had been removed. This requirement is now therefore currently met. The last inspection report recorded that the fire extinguisher in the lounge was not fixed to the wall in its usual place but free standing by the door to the garden. The following new requirement was then set: Fire extinguishers must be fixed to the wall safely where they are to be used and not left on the floor. This had occurred by the time of this inspection and this requirement is now met. All of the health and safety policies and procedures relevant to this Standard were seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 38 were also present except an up to date gas safety certificate. The following new requirement is now therefore set: An up to date gas safety certificate must be sent into the Commission. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 4 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clifton Manor Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 2 2 x G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 28 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. Standard 42 Regulation 12[1] Requirement An up to date gas safety certificate must be sent into the Commission. Timescale for action 1/9/2005 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 14 Good Practice Recommendations Each resident should be offered a seven-day holiday paid for by the placing authority as a part of the contracted price. This would facilitate more funding and additional holidays for residents that they do not have to pay for. The service users preferences for how their support with personal care is carried out should be recorded. At least 50 of care staff should be qualified at NVQ Level 2 by 2005 (32.6). This was not re-assessed for compliance on this occasion. The registered manager should be qualified to NVQ Level 4 in Management and Care by 2005 (37.2).This was not reG53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 29 2. 3. 4. 18 32 37 Clifton Manor 5. 41 assessed for compliance on this occasion. It is strongly recommended that records concerning service users are restored to minimally daily entries - this ties in with a focus on specific care plan aims and goals (41.1 3). 6. Clifton Manor G53 S7195 CliftonManor V198423 010805 stage4.doc Version 1.30 Page 30 Commission for Social Care Inspection 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. 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