CARE HOME ADULTS 18-65
Clifton Manor 67 Manor Road Wallington Surrey SM6 0DE Lead Inspector
Barry Khabbazi Unannounced Inspection 20 May 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 CliftonManorUI V227454 200505 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 CliftonManorUI V227454 200505 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 a learning disability; 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, office room and ‘sensory 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 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 8.20 a.m. This early unannounced inspection was timed to enable all the residents to be met before they went to their day activities. The inspection took place over 1.5 hours. The main aim of this inspection was for the inspector to monitor how the home is complying with last year’s requirements. In addition the it was also useful for the inspector to re-acquaint himself with the residents and observe the morning routine. The inspector was able to speak to all the residents on this occasion. During this inspection the staff were interviewed and records, care plans and the building were examined. The manager was not present during this inspection and the residents left for day activities at around 9.30am. What the service does well: What has improved since the last inspection? What they could do better:
It was not possible to fully assess this section as the manager was not present during this unannounced inspection to provide access to some of the documents pertaining to previous requirements. Where it has not been
Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 6 possible to re-assess compliance with previous requirements this is recorded in bold print below. The daily notes are not sufficiently detailed and do not reflect how needs in the care plan were met on that day. This could be seen as reflection of the lack of staffs’ knowledge of the needs of the residents and evidence that these needs are not being met. Packets of food products, once opened, are not in sealed containers to avoid the risk of contamination/infestation. The timescale of the 9/9/04 for this existing requirement has not been met. Fridge temperatures are not regularly recorded which could put residents at risk of infection. The home’s Abuse Policy needs further clarification to ensure that staff understand the procedures fully. It was not possible to re-assess the existing requirement regarding this for compliance on this occasion. At least 50 of care staff should be qualified at NVQ Level 2 by 2005 so that the home can provide suitably qualified staff. It was not possible to reassess the existing recommendation regarding this for compliance on this occasion. Staff should be required to sign 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. It was not possible to reassess the existing recommendation regarding this for compliance on this occasion. The registered manager should be qualified to NVQ Level 4 in Management and Care by 2005 to ensure that a suitably qualified manager is employed at this home. It was not possible to re-assess the existing requirement regarding this for compliance on this occasion. All residents 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. It was not possible to reassess the existing requirement regarding this for compliance on this occasion. It is strongly recommended that records concerning residents are restored to minimally daily entries - this tied in with a focus on specific care plan aims and goals (41.1 3). It was not possible to re-assess the existing recommendation regarding this for compliance on this occasion. Routine checks (minimally monthly) and the maintenance of any wheelchairs used at the home must be recorded to show adequate precautions are taken to
Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 7 ensure the safety of users. . It was not possible to re-assess the existing requirement regarding this for compliance on this occasion. Wedges used to hold doors open (such as seen in bedrooms) must be avoided at all costs - with approved devices being used when necessary to protect the residents from fire risks. An existing requirement regarding this remains unmet. Fire extinguishers must be fixed to the wall safely where they are to be used 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. 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 CliftonManorUI V227454 200505 stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This group of standards were not assessed on this occasion. EVIDENCE: This group of standards were not assessed on this occasion. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 Although the residents’ 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 resident’s known and changing needs. EVIDENCE: The last 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 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 daily notes were examined at this inspection. There were many dates without entries and records did not demonstrate how the care plan was met on
Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 11 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. Although this affects this standard, a recommendation regarding this remains under Standard 41 and will not be repeated here. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 12 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) 17 The safe storage of the residents’ food is not being maintained to a satisfactory standard. EVIDENCE: The last announced inspection report recorded under Standard 7 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). The following unannounced inspection recorded that this remained unmet. At this inspection the above requirement was still unmet. A part of a cake was in a container without a lid on it, two pieces of dirty cheese squares were not covered properly and not dated {the staff member was asked if he would eat this, to which he replied no} and something was in a blue bag in the ice box in the fridge which also did not have a date on it. The previous requirement therefore remains unmet and in force. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 13 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. The following requirement is now set: Fridge temperatures must be checked on a daily basis. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This group of standards were not assessed on this occasion. EVIDENCE: This group of standards were not assessed on this occasion. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 15 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) This group of standards were not assessed on this occasion. EVIDENCE: This group of standards were not assessed on this occasion. 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). The manager was not present on the day of this inspection and the residents and staff all left for day activities about an hour after the inspector ariving. Due to this it was not possible to re-assess this existing recommendation for compliance on this occasion. This recommendation will therefore remain in force until the home has evidenced compliance. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 16 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) This group of standards were not assessed on this occasion. EVIDENCE: This group of standards were not assessed on this occasion. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 17 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) This group of standards were not assessed on this occasion. EVIDENCE: This group of standards were not assessed on this occasion. The last inspection report contained 2 recommendations under this group of standards. 1, 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). 2, At least 50 of care staff should be qualified at NVQ Level 2 by 2005 (32.6). The manager was not present on the day of this inspection and the residents and staff all left for day activities about an hour after the inspector ariving. Due to this it was not possible to re-assess this existing recommendation for compliance on this occasion. This recommendation will therefore remain in force until the home has evidenced compliance. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 18 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) 42 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: The last inspection report contained 2 requirements and 2 recommendations under this group of standards, that were not re-assessed for compliance on this occasion. 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). 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). Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 19 1, 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). 2, The registered manager should be qualified to NVQ Level 4 in Management and Care by 2005 (37.2). The manager was not present on the day of this inspection and the residents and staff all left for day activities about an hour after the inspector ariving. Due to this it was not possible to re-assess these 2 existing requirements and 2 existing recommendations for compliance on this occasion. These requirements and recommendations will therefore remain in force until the home has evidenced compliance. The last inspection report recorded that all the procedures and testing of systems required by Standard 48 were also present and satisfactory. 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’ The magnetic closing devise was not able to be used at this inspection because the number of coats hanging behind this door prevented the contacts from connecting. The door was therefore held open by a chair and could not self close in the event of a fire. This existing requirement therefore remains in force. The fire extinguisher in the lounge was not fixed to the wall in it’s usual place but free standing by the door to the garden. Replacing these in the appropriate place will ensure that the extinguishers do not become damaged, are available when required and do not present a tripping hazard. The following new requirement is now therefore set: Fire extinguishers must be fixed to the wall safely where they are to be used and not left on the floor. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 20 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 x 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 x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Clifton Manor Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 21 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. Standard 17 Regulation 16(2) (h) (i) Requirement Packets of food products, once opened, must be kept in sealed containers to avoid the risk of contamination/infestation (17.1 & 42.1-3). Timescale of 09.09.04 not met. fridge tempritures must be checked on a daily basis. 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). Timescale of 09.09.04 not met. 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). Timescale of 30.09.04 not met. Wedges used to hold doors open (such as seen in bedrooms) must be avoided at all costs - with approved devices being used when necessary (42.2ii).Timescale of 21.02.05 not met. Timescale for action 28.02.05 2. 3. 17 41 13[3] 15(1) (2) 1.7.2005 21.03.05 4. 42 13(4) & 23(2)(c 21.03.05 5. 42 13(4) 21.02.05 Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 22 6. 7. 42 13[4] Fire extinguishers must be fixed to the wall safely where they are to be left on the floor. 1.8.2005 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 23 Good Practice Recommendations The home’s Abuse Policy should 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 was not reassessed for compliance on this occasion. 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 was not re-assessed for compliance on this occasion. 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 reassessed for compliance on this occasion. 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). 2. 31 3. 4. 5. 32 37 41 6. Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Clifton Manor G53 S7195 CliftonManorUI V227454 200505 stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
