Inspection on 15/10/07 for Clifton Manor

This inspection was carried out on 15th October 2007.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clifton Manor 13/10/08

Clifton Manor 19/02/07

Clifton Manor 01/08/05

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 Key Unannounced Inspection 15th 30th of October 2007 08:30 Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 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 Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Manor Address 67 Manor Road Wallington Surrey SM6 0DE 020 8669 5305 020 8669 3060 jackie.lehane@cliftonmanor.com www.bdcsupportingservices.co.uk Mr Sheik Mohamedally Mrs Patricia Mohamedally Mrs Jacqueline Catherine Lehane Care Home 8 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) Category(ies) of Learning disability (8) registration, with number of places Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/08/07 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 towns shops, pubs, churches, and public transport links - both by bus and train (Wallington railway station is nearby). The home provides care for eight adults with severe to moderate learning disabilities; 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 DS0000007195.V352502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. As the manager was not available to provide information regarding some key standards {for example staff recruitment files}, a separate meeting with the manager was also arranged. The manager was interviewed, and records, policies, care plans, and the building were also examined. Some service users talked about recent activities and outings they had attended and visits to friends. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. Staff were seen to be supportive and responsive to service users’ needs. A marked improvement in care planning was observed at this inspection. The new care plans were well thought out and clarified all the residents’ needs and how they are to be met. What the service does well: 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 in previous inspection reports. 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 more detail in the last report, for further supporting evidence. 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. In addition new good practice has been identified with monthly reviews also occurring. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: There had been no new service users since the last inspection to enable this standard to be re-assessed. However, the newest service user’s file were examined at the 2006 inspection and these contained the care management assessment and care plan as required by this Standard. In addition the home has completed its own assessment of need. This standard will therefore remain met until it can be re-assessed. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care now record all needs and are regularly updated. This helps staff know all a service users needs and how they are to be met. Service users are supported to make decisions about their lives. Service users are consulted on all aspects of life in the home and these views are implemented where appropriate. Standard 8 is exceeded. Risk assessments contain all the information required as including this information could reduce unnecessary restrictions of liberty for the service users. EVIDENCE: Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 10 A marked improvement in care planning was observed at this inspection. The last inspection report contained the following two requirements: 1, Care Plans must record all a service user’s needs, and in particular, cultural and religious needs. If there are no known needs in a specific area, this also must be recorded in the care plan and the section not simply left blank. 2, Care Plans must be reviewed on a six monthly basis. The new care plans were well thought out and clarified all the residents’ needs and how they are to be met. These are also now reviewed on a six monthly basis as required. Both these requirements are now met well. In addition new good practice has been identified with monthly reviews also occurring. The service users’ preferences for how their support with personal care is carried out is now being recorded so that staff can carry out this support in the manner that service users prefer. Where the home manages a service user’s money, financial records and care plans clarify when change from a service user’s spending money is kept by themselves and will therefore not fully tally with receipts records. 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 last inspection report for further supporting evidence. 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 of the last report. This is reflected by Standard 8 – ‘service user consultation and participation in the running of the home’, 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 Standard 9, including what training or other options have been explored before a restraint or restriction of liberty is applied. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards; 12 13, 14, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to be part of the local community and are able to take part in appropriate activities and holidays. This promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents’ rights are respected and responsibilities recognised. The food provided is sufficient in quantity, and it is sufficiently nutritious, which is important to ensure good health. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 12 EVIDENCE: Evidence was provided of service users continuing to attend college 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. Some service users were seen to be eagerly waiting to go out for the day and one told the inspector about activities and outings she had attended recently. Some service users talked about recent activities and outings they had attended and visits to friends. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. Staff were seen to be supportive and responsive to service users’ needs. 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’ rooms. 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 have not provided this yet. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 13 Although the following recommendation is technically required it is recognised that it refers more to the placing authority than the home and as the home is addressing this to the degree it can Standard 14 will remain met. Each resident should be offered a seven-day holiday paid for by the placing authority as a part of the contracted price. The daily routines and house rules do generally promote independence and choice. See also the service user inspection pilot recorded in the last inspection report 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 includes alternatives if service users want 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. Previous service user surveys state that many of the residents like the food at this home. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is now carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed as staff have had approved and accredited medication administration training to promote safer medication administration. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 15 EVIDENCE: The service users’ preferences for how their support with personal care is carried out are now being recorded so that staff can carry out this support in the manner that service users prefer. There are currently 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 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 is 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. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted upon. 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 generally facilitate protecting service users from abuse. EVIDENCE: The Commission received a concern that service users had no choice about going to the daycentre. The manager showed records of where a service user had been supported to stay at the home on a daycentre day when she didn’t feel well enough to go to the daycentre. In addition, on the first day of this inspection, one service user stayed at the home instead of going to the daycentre. The concern was found to be unsubstantiated. There had been no official complaints from service users or relatives since the last inspection. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 17 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 the complaints policy is also available in more accessible pictorial formats. The home does have a copy 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. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 24, 25, and, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 generally hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 19 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. 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. Previous service user surveys indicated that most service users liked their rooms. 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. The building was clean and tidy and was generally free of offensive odours, although this was not the case for all bathrooms on this occasion. 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 DS0000007195.V352502.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are not supported by a staff group where 50 or more have the required qualifications. Achieving this will raise the quality of staff, their knowledge and their practices. The home’s recruitment procedures need to be tightened up to better protect the residents through vigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 21 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. The last {2005} inspection report contained the following recommendation under Standard 32: At least 50 of care staff should be qualified at NVQ Level 2 by 2005 (32.6). At the time this recommendation was made the deadline of the end of 2005 recorded under Standard 32 had not expired. A recommendation only was therefore made. As this deadline has now expired and the recommendation remains unmet, the previous recommendation has been upgraded to the following requirement: At least 50 of care staff must be qualified at NVQ Level 2 (32.6). It is to be noted however, that one staff member is also awaiting verification. If no staff leave, this will achieve the 50 required. The timescale will therefore be extended. There had been no new staff since the last inspection. It was therefore not possible to re-assess the recruitment standard. However it was met at the last inspection and will remain met until reassessment is possible. The last report identified the following recruitment procedures: This home has an equal opportunities recruitment policy. The staff files contained Criminal Record Bureau checks, interview notes, statements of terms and conditions, identification checks, two written references and staff photographs. 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. Supervision had been previously exceeded in frequency but could not be evidenced as exceeded this year. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home although the manager still needs to complete the required qualification. Service users benefit from the ethos of inclusion and leadership of the home. 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, more risk assessments are needed in some areas to clarify safety protocols. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 23 EVIDENCE: The last annual inspection report recorded that the manager could not meet the inspector or provide a deputy to provide access to staff files over a one week period. This did raise concerns regarding the level of deputisation in the manager’s absence and it was decided to monitor the situation. The manager was available at the last inspection and a new post of area manager has been created who is now also available if needed in the manager’s absence. This concern has now been addressed. The last inspection report contained the following requirement under Standard 37: The registered manager must be qualified to NVQ Level 4 in Management and Care (37.2). Although not available it is recognised that the manger is currently undertaking this qualification and awating verification. The timescale will therefore be extended. 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 in the last inspection report. 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 more detail in the last report, for further supporting evidence. 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. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 24 All of the health and safety policies and procedures relevant to Standard 42 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 42 were also present except for Risk assessment for the water supply in regards to quality and temperature at the outlets. This is needed to reduce the risk of infection and scalding. The following two requirements are now set to address this: Risk assessments must be produced to ascertain the safety of the water system with regards to the risk of infection, and any action required to maintain its safety. Risk assessments must be produced to ascertain the safety of the water outlets with regards to the risk of scalding and any action required to maintain its safety. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 4 3 x x 2 x Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 26 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 YA37 Regulation 9[2] i Requirement The registered manager should be qualified to NVQ Level 4 in Management and Care. At least 50 of care staff should be qualified at NVQ Level 2 Risk assessments must be produced to ascertain the safety of the water system with regards to the risk of infection, and any action required to maintain its safety. Risk assessments must be produced to ascertain the safety of the water outlets with regards to the risk of scalding and any action required to maintain its safety. Timescale for action 01/04/08 2. 3. YA32 YA42 18[1] 13 01/04/08 01/01/08 4. YA42 12 01/01/08 Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 27 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 YA23 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. Clifton Manor DS0000007195.V352502.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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