Inspection on 19/02/07 for Clifton Manor

This inspection was carried out on 19th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 8 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 15/10/07

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 19th February 2007 9:30 Clifton Manor DS0000007195.V330523.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.V330523.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.V330523.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.V330523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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 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.V330523.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. The home was found to be generally well run but with a slightly increased level of minor shortfalls compared to the last inspection. However, one new Standard has been exceeded, ‘supervision’. There are 5 new requirements in this report. 2 of these refer to previous shortfalls regarding reviews and care plan details that were previously identified as shortfalls, then addressed and have now slipped back again. 2 old unmet recommendations for staff and management qualifications have been upgraded to requirements as the deadline of 2005 recorded for these in the Standards has elapsed. In addition one other recommendation {the service users’ preferences for how their support with personal care is carried out} has been changed to a requirement as it has remained unmet since 2005. 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. As no specific negative outcomes were identified to have directly arisen from this, a requirement has not been made at this time. However, the effectiveness of the deputisation system in the manager’s absence will be monitored between this and the next inspection. Some service users talked about recent activities and outings they had attended. 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. Although a number of minor shortfalls were identified at this inspection, outcomes for service users remain generally good, and no areas of serious concern were identified at this inspection, although the slippage in care plan quality of information and frequency of review is of some concern. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? New carpet has been laid in the lounge and hallway. Standard 36 ‘Supervision frequency’, was evidenced as exceeded this year, this ensures a well guided and appraised staff group. There had been an improvement in the daily notes which are now sufficiently detailed and reflect how needs in the care plan were met on that day. The gas safety certificate has been produced to confirm that the gas is safe. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 7 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.V330523.R01.S.doc Version 5.2 Page 8 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.V330523.R01.S.doc Version 5.2 Page 9 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. The newest service user’s file were examined at the last 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. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 10 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 poor. This judgement has been made using available evidence including a visit to this service. Plans of care do not record all needs and are not regularly updated. Service users are supported to make decisions about their lives although these areas needed to be better recorded. 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. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service users 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. The home’s care planning documents are comprehensive, and set out in a concise manner and show how most of a service user’s needs are to be met. Care plans sampled did not have any cultural or religious needs recorded or a record that the service user has no identified cultural or religious needs. The section for this in the care plan had simply been left blank. This section needs to be filled in {as do all sections} even if there are no known needs in this area, so that evidence that any cultural or religious needs have been fully assessed is recorded. The following new requirement is set to address this under Standard 6: Care Plans must record all a service users 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. In addition care plans sampled had not been reviewed on a six monthly basis. The following requirement is set to address this also under Standard 6: Care Plans must be reviewed on a six monthly basis. The 2 new requirements under Standard 6 above were previously identified as shortfalls, then addressed and have now slipped back again. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. The service users each have a cash box for their personal allowance. When money is withdrawn from the cash box, the balance is checked and it has to be signed for by two staff members. Each of the service users also has their own savings account. A concern was brought to the inspector’s attention regarding another home in the group, regarding how residents’ spending money was recorded. The concern was that when a service user draws out spending money that is held by the home and keep any change as opposed to returning it for safe keeping, there are no records of this. This would allow undesirable staff to keep the change themselves and there would be no way to check whether this had occurred with the current recording system. As the same recording system is used at this home, records were examined. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 12 It was found that there were indeed two systems operation, one where money not spent is returned for safe keeping and recorded, and one where the service user is sufficiently independent to keep the change themselves. It was also found that records did not clarify this for the latter system, creating incomplete records for the person concerned and leaving staff open to potential undefendable allegations. To protect staff, the organisation, and residents from this, the following requirement is now set: Where the home manages a service user’s money, financial records and care plans must 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.V330523.R01.S.doc Version 5.2 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. 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 recognises. The food provided is sufficient in quantity, and it is sufficiently nutritious, which is important to ensure good health. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 14 EVIDENCE: Evidence was provided of service users attending 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. 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. 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. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 15 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 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. Previous service user surveys state that many of the residents like the food at this home. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is not always 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. EVIDENCE: The last inspection report recorded the following recommendation under Standard 18; The service users’ preferences for how their support with personal care is carried out should be recorded. This is needed to ensure that staff know and Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 17 comply with residents’ preferences as to how their personal care is carried out. This had not been implemented by the time of this inspection. As this recommendation was set in 2005 and remains unmet, the significance and potential shortfall increases. To reflect that increase in significance and potential shortfall, the previous recommendation is now made the following requirement: The service users’ preferences for how their support with personal care is carried out must be recorded. 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.V330523.R01.S.doc Version 5.2 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. 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: 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 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.V330523.R01.S.doc Version 5.2 Page 19 The home’s Abuse Policy refers to the situation where an allegation has been made, that for a service user’s and staff member’s safety, ‘suspension from work - without prejudice’ may well be temporarily invoked. The caviat of ‘generally’ in the judgement for this section refers to the need to tighten up recording of service users spending money for the protection of service users and staff, recorded under Standard 7. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 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. 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.V330523.R01.S.doc Version 5.2 Page 21 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. 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.V330523.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34, 35, 36 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 the 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 insure that they are appropriately trained. The staff are well supervised and receive supervision above the required level. Standard 36 is therefore exceeded. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 23 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 the home is close to achieving this target of 50 . This home has an equal opportunities recruitment policy. The staff files sampled contained Criminal Record Bureau checks, interview notes, statements of terms and conditions, identification checks, two written references and staff photographs. However, two Criminal Record Bureau checks were not specific to the setting. These were obtained from previous employment settings. Criminal Record Bureau checks must be specific to the setting to be valid. This is because a CRB from a different employer may not have all the required checks on it, regardless of whether it is an enhanced check or not, as the checks currently undertaken depend on the type of employment. It is anticipated that CRB legislation will be changed this year to address this anomaly. However, the lack of setting specific CRBs currently do create a shortfall under this Standard. The following requirement is now therefore set: Criminal Record Bureau checks must be specific to the setting to be valid. 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. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 24 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. Standard 36 ‘Supervision frequency’, was evidenced as exceeded in frequency this year, this ensures a well guided and appraised staff group. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 25 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, 41 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 provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. 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. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 26 Service users rights and interests are generally promoted by the home’s policies and record keeping but this could be improved in some areas. Although the home generally promotes the health and safety of the residents, more diligence in monitoring and maintaining annual system safety checks is needed. EVIDENCE: 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. As no specific negative outcomes were identified to have directly arisen from this, a requirement has not been made at this time. However, the effectiveness of deputisation systems in the manager’s absence will be monitored between this and the next inspection. The last inspection report contained the following requirement under Standard 37: The registered manager should be qualified to NVQ Level 4 in Management and Care by 2005 (37.2). At the time this recommendation was made the deadline of the end of 2005 recorded under Standard 37 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: The registered manager must be qualified to NVQ Level 4 in Management and Care by (37.2). It is however recognised that the manger is currently undertaking this qualification. 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 Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 27 development plan open to service users through an annual quality assurance meeting. The last inspection report contained the following requirement: 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). Daily reccords are now more regular and refer to care porvided. This recommendation is now therefore met. Service users rights and interests are generally promoted by the home’s other policies and record keeping but this could be improved in some areas. Standard 7 refers to a minor shortfall in the level of protection provided by spending money records. This does also create a minor shortfall here under Standard 41, but the requirement will not be repeated here. See standard 7 for details. The last inspection report contained the following requirement under Standard 42: An up to date gas safety certificate must be sent into the Commission. This has now occurred and this requirement is now met. 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 an up to portable appliance safety check certificate. The following new requirement is now therefore set: A copy of the Portable Appliance testing report must be sent to the commission. Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 28 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 4 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 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 2 3 3 x 2 3 3 x 2 2 x Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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 YA18 Regulation 12[2] Requirement The service users’ preferences for how their support with personal care is carried out must be recorded. At least 50 of care staff should be qualified at NVQ Level 2 The registered manager should be qualified to NVQ Level 4 in Management and Care. Care Plans must be reviewed on a six monthly basis. Care Plans must record all a service user’s needs, and in particular, cultural and religious needs. If there are no known need in a specific area, this also must be recorded in the plan. Criminal Record Bureau checks must be specific to the setting to be valid. A copy of the Portable Appliance testing report must be sent to the Commission. Where the home manages a service user’s money, financial records and care plans must clarify, when change from a service user’s spending money is kept by themselves and will therefore not fully tally with receipts records. DS0000007195.V330523.R01.S.doc Timescale for action 01/05/07 2. 3. 4. 5. YA32 YA37 YA6 YA6 18[1] 9(2) i 01/09/07 01/09/07 01/04/07 01/04/07 15 15 6. 7. 8. YA34 YA42 YA7 17 12 13[1]b 01/04/07 01/05/07 01/05/07 Clifton Manor Version 5.2 Page 30 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 YA14 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.V330523.R01.S.doc Version 5.2 Page 31 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. Extracts may not be used or reproduced without the express permission of CSCI Clifton Manor DS0000007195.V330523.R01.S.doc Version 5.2 Page 32 - 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. 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