Inspection on 24/07/08 for Clifton Manor Care Home

This inspection was carried out on 24th July 2008.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clifton Manor Care Home 19/11/08

Clifton Manor Care Home 12/06/07

Clifton Manor Care Home 12/04/06

Clifton Manor Care Home 01/11/05

Clifton Manor Care Home 21/06/05

Clifton Manor Care Home 14/12/04

Clifton Manor Care Home 10/08/04

Clifton Manor Care Home 18/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Clifton Manor Care Home Rivergreen Clifton Nottingham NG11 8AW Lead Inspector Karmon Hawley Unannounced Inspection 24th July 2008 09:45 X10015.doc Version 1.40 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 Care Home DS0000002299.V368945.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Manor Care Home Address Rivergreen Clifton Nottingham NG11 8AW 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) 0115 984 5859 0115 984 5859 clifton.manor@hotmail.co.uk clifton.manor@hotmail.co.uk Monarch Healthcare Ltd Mrs Deborah Kelly Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Clifton Manor Care Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following category:Old age, not falling within any other category (OP) 46 Within this number, one named individual may be accommodated at Clifton Manor Care Home under the category Mental Disorder over 65 years of age MD(E) See variation applications dated 01.08.05 and 13.09.05 The maxim number of persons to be accommodated at Clifton Manor Care Home is 46 12th June 2007 2. 3. Date of last inspection Brief Description of the Service: Clifton Manor Care Home is a purpose built unit situated within a housing estate in a suburb south of Nottingham city centre. The accommodation is on two floors with access provided by both stairs and a lift. The home is adjoined to Clifton Manor Nursing Home, which is registered separately by the Commission for Social Care Inspection (CSCI). Local shops are close by as are public transport services to Nottingham. The home provides accommodation and personal care to a maximum of 46 older people over the age of 65 years. The current weekly fees for the care home range from £365 - £465, these fees do not cover the cost of hairdressing or chiropody. Information about the fees and the care home is made available at the point of enquiry. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star this means that people who use the service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people living at the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One regulatory inspector conducted the unannounced visit over 1 day, including the lunchtime period A review of all the information we have received about the home was considered in planning this visit and this helped decide what areas were looked at. The main method of inspection we use is called ‘case tracking’ which involves selecting the care plans of 4 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The registered provider, members of staff and people who use the service were spoken with as part of this visit. A partial tour was undertaken by the regulatory inspector, which included looking at the bedrooms of those people who we case tracked and communal areas of the home. What the service does well: People using the service are supported to access specialist services such as the GP, district nurse and opticians as needed. People using the service are supported to live a life of their choosing which satisfies their needs and they are enabled to maintain relationships that are important to them. People using the service said, ‘I am settled living here, and I can choose what I do throughout the day,’ I am very happy living here, it is lovely, I enjoy the activities, we have a good laugh and a sing song,’ ‘I enjoy the activities on offer, we have regular BBQ’s’ and ‘I go out shopping with the staff.’ Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 6 Two people using the service also confirmed that visitors could come at anytime and said, ‘my family visit and take me out,’ and ‘I can have visitors at anytime.’ A wholesome and appealing diet is on offer for people using the service and specialist diets are catered for. People using the service are protected from abuse and are assured that their complaints will be listened to and resolved. The environment is clean and comfortable, offering people who live there a homely environment. People using the service are supported by sufficient numbers of staff to meet their needs. People using the service are protected from unsuitable people being employed. Staff training in mandatory areas is at a good standard and staff are able to discuss how they use their training in their every day work to support people using the service. What has improved since the last inspection? What they could do better: Plans of care must be in place for all specific needs and contain enough information to ensure that the needs of people using the service are fully met. Plans of care must be updated when significant changes occur to ensure the continuity of care for the person using the service. Plans of care must be person centred to ensure that people using the service receive care in the way that they prefer. Risk assessments for all highlighted risks must be in place to ensure that people using the service are protected. Systems must be in place to ensure that medication is administered correctly and recorded following administration to ensure people using the service receive medication as prescribed. This is an outstanding requirement and enforcement action is now being considered. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 7 All staff must receive training in regard to the specific needs of people using the service such as diabetes mellitus, epilepsy and the safe use of bedrails to ensure that people using the service are protected and their needs are met. 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 Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As the service is not registered for people with dementia care needs there is a risk that people’s needs may not be fully met in appropriate surroundings. The service does not offer intermediate care. EVIDENCE: To establish if staff can meet a person’s needs before they move into the care home an assessment is carried out. Currently the system in use does not enable this information to be separated from the main admission assessment. To remedy this the manager is going to implementing a new preadmission assessment to resolve this issue. People who may wish to use the service can visit and spend time at the home to get a feel for what it would be like to live there before they make a decision to move in. One person using the service said, ‘I am here for just two weeks, I can’t remember if I came to look around before hand.’ Staff spoken with confirmed that their relative had been to visit the care home before admission. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 10 The service does not offer intermediate care. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The needs of people using the service are not protected from all identified risks and their needs may not be fully met due to the development needed in regard to care planning. People using the service are not protected by the medication policies and procedures in place. EVIDENCE: People using the service undergo assessments in regard to the activities of daily living so that their needs may be established and plans of care negotiated. Within case files examined some plans of care are task focussed and did not reflect individual choices and preferences despite these being available within the assessment information. Also information in some plans of care is brief and do not outline fully the support needed to meet the person’s need. There are occasions where plans of care are not updated when significant changes have occurred which may affect the continuity of care received. Although there is a general risk assessment in each person’s file, complex needs such as diabetes mellitus and the safe use of bedrails are not addressed. On discussing these issues with staff they were not able to fully Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 12 explain all the methods and checks needed to ensure that the person remained safe. People using the service all expressed that their needs are met and the staff are very kind and caring. People using the service are supported to access specialist services such as the GP, district nurse and opticians as needed. One person using the service said that they could see the doctor if they were unwell and that the optician had been to see them about their glasses. During the tour of the care home relevant equipment for the maintenance of healthy skin such as specialist cushions were in place. Staff spoken with said that they received a good level of support from the district nurses and they got all the necessary equipment they needed for people using the service. Whilst observing the lunchtime medication round, poor medication practices in regard to the safe administration of medicines was witnessed. Medication had been left unattended on the medication trolley whilst the staff member attended to another person using the service. This resulted in a Code B being served upon the care home as a requirement had been set at the previous inspection in regard to poor medication practices. This gave us the powers to seize documentation and evidence such as the staff members training file, policies and procedures and the medication records of the people using the service who’s medication had been left unattended, as a breach in the Care Home Regulations was suspected. This evidence is currently being analysed in regard to further action that may be taken to gain compliance with the regulations. Other members of staff spoken with were able to discuss good practice in regard to the administration of medication. Staff files examined showed that staff who administer medication have undertaken training in this. All other records examined in regard to medication were maintained as required. One person using the service said, ‘the staff look after all my medication for me, which is good.’ People spoken with said staff were very kind and respectful. One person said, ‘the staff knock on my door before they come in,’ whereas one person said, ‘staff sometimes knock on my door before they come in but sometimes they do not, I am not bothered either way.’ Staff spoken with stated that they knocked on people’s doors before entering and ensured that they maintained people’s dignity whilst offering personal care. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 13 Staff were observed to treat people using the service with respect during the visit. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported to live a life of their choosing which satisfies their needs and they are enabled to maintain relationships that are important to them. EVIDENCE: Staff spoken with stated that there are a variety of activities on offer for people to join in if they wished. Staff were observed to spend time talking with people and one was playing dominoes with a small group of people using the service. People using the service said, ‘I am settled living here, and I can choose what I do throughout the day,’ I am very happy living here, it is lovely, I enjoy the activities, we have a good laugh and a sing song,’ ‘I enjoy the activities on offer, we have regular BBQ’s’ and ‘I go out shopping with the staff.’ Staff spoken with said that the routine of the care home is flexible and they support people to make their own choices. People using the service said, ‘I can get up and go to bed when I want, I have a cup of tea in my room before breakfast,’ and ‘the Reverend comes to the care home, I am pleased about that as I can’t get to church myself.’ People using the service were observed to Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 15 move freely around the care home and occupy themselves when not joining in activities. Several visitors were seen throughout the visit and when spoken with a relative stated that they were always made welcome and were offered a drink. Two people using the service also confirmed that visitors could come at anytime and said, ‘my family visit and take me out,’ and ‘I can have visitors at anytime.’ One person using the service was observed to be assisted to their bedroom so that they could see their visitors in private. Staff spoken with were able to discuss how they meet the differing needs of people living in the care home and how they support people in maintaining personal relationships. Staff have recently undertaken training in ‘expressing sexuality in dementia’ and could explain the importance this may still be to people using the service and how they could support them appropriately. A well-balanced and wholesome diet is on offer with choices available at each meal. The lunchtime meal on the day of the visit was plentiful and looked very well presented. People using the service said, ‘the food is very good, we have nice meals,’ ‘there is plenty to eat,’ and ‘the food is very good and tasty.’ Staff spoken with discussed the special diets that some people using the service need and how these are catered for. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are protected from abuse and are assured that their complaints will be listened to and resolved. EVIDENCE: People using the service have access to the complaints policy and a copy of this is within each person’s room. People using the service said, ‘the staff are very kind, friendly and approachable, they listen to me if I have any problems,’ and ‘I do not have any complaints. I am very happy here.’ Staff spoken with were able to discuss how they would deal with a complaint should one be received. A concern has arisen and a relative had made a complaint known. Although this was not logged in the complaints record, there was evidence within daily records, which demonstrated that this had been investigated and resolved. Twenty one members of staff have undertaken training in the protection of vulnerable adults. Staff spoken with were aware of their roles and responsibilities in regard to this and were able to discuss what they felt constituted abuse and how they would report bad practice. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 17 Several people using the service said that they were settled and happy living at the care home and one person said that it made them feel safe living at the care home. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service live in a comfortable and homely environment, which is well maintained. EVIDENCE: The interior of the care home has recently been redecorated and new furniture purchased. One person using the service commented on how nice the lounge looked now that this had been done. The garden has also been landscaped and several people using the service were sitting outside in the garden on the day of the visit. There are various seating areas throughout the care home where people were observed to spend their time as they wished. The home was clean and tidy in all areas accessed during the brief tour of the care home. People’s rooms were personalised with their belongings and one Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 19 person spoken with said that they had brought a number of things with them to make it feel more homely. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported by sufficient numbers of staff to meet their needs. People using the service are protected from unsuitable people being employed. EVIDENCE: Staff spoken with said, ‘the staff team all get on well together and there are enough staff available to meet people’s needs,’ and ‘we work well together as a team.’ People using the service confirmed that there are enough staff available and said, ‘the staff help me to use the lift when I need to,’ and ‘there are enough staff, they are really good and they help me.’ Staff were observed to be available to support people using the service throughout the visit. New members of staff undertake and induction to ensure that they are aware of their roles and responsibilities on commencing employment. One member of staff spoken with confirmed that they had undertaken an induction and said, ’it was very helpful.’ There was evidence observed in staff personnel files to demonstrate that inductions are taking place. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 21 To ensure that staff have the necessary skills and knowledge to look after people using the service over 50 of staff have attained the National Vocational Qualification level 2 or above (a nationally recognised work and theory based qualification). Two members of staff spoken with confirmed that they had undertaken this training and there was evidence within staff personnel files to confirm this. All staff employed undergo the necessary checks required by law to ensure that people using the service are protected from unsuitable people being employed. Staff spoken with confirmed that they had undertaken a Criminal Record Bureau check (a police check to see if a person has a police caution or criminal record) before commencing employment. Two references were available within staff files examined with the exception of one, however this was along term member of staff, therefore the manager stated that they would complete a character reference for this person. Staff spoken with said that they felt supported in their training and development needs and that they received sufficient training to meet the needs of people using the service. Staff training in mandatory areas was up to date and there was a good attendance rate for all staff. Staff spoken with were able to discuss the needs of people in regard to complex needs such as diabetes mellitus and epilepsy at a basic level only. This was discussed with the manager who stated that she would address this issue. One person using the service spoken with said, ‘I feel that the staff are well trained to look after me, they know what they are doing.’ One relative spoken with said, ‘the staff work very hard and they are good at their job.’ Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported and enabled to express their views and opinions about their life in the care home to ensure that their needs are met. EVIDENCE: The manager remains up to date with training and she has completed the Registered Managers Award, which is designed to enhance management skills. One staff member spoken with said, ‘the manager is very supportive and approachable at all times.’ One relative spoken with said that they felt that the home was well run and managed. People using the service, relatives, staff and visiting professional such as GP’s and district nurses have had the opportunity to express their views and opinions about the service in the form of a questionnaire. The results of the last survey showed that mainly positive comments were received such as, Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 23 ‘staff are always approachable and pleasant, the home is always warm and friendly,’ ‘the food is very good and we always get a choice,’ and ‘the quality of care we provide is good.’ There were only a few comments about how the service may be improved upon such as, ‘we would like more films and books from early years.’ An action plan was in place to address these issues. One member of staff spoken with said that they had regular staff meetings and meetings for people using the service, which prove beneficial and give people the opportunity to express their views. The manager undertakes audits in regard to falls and accidents to ensure that these are monitored and plans are put into place to address any issues of concern if needs be. People using the service can have their money kept in safe keeping in the office safe should they wish. Four personal allowance accounts were examined, which corresponded with the accounting sheet. Records of all transactions are kept and receipts are available. Financial arrangements and responsibilities are recorded within people’s plans of care so that staff are aware of the arrangements. Maintenance certificates examined demonstrated that regular checks and servicing are taking place on equipment such as manual handling aids and the lift. The manager carries out a health and safety audit once a month to ensure that any areas of concern are addressed immediately. There were no obvious hazards observed during the tour of the care home. Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Timescale for action Plans of care must be in place for 05/09/08 all specific needs and contain enough information to ensure that the needs of people using the service are fully met. Plans of care must be updated 05/09/08 when significant changes occur to ensure the continuity of care for the person using the service. Plans of care must be person 05/09/08 centred to ensure that people using the service receive care in the way that they prefer. Risk assessments for all 21/08/08 highlighted risks must be in place to ensure that people using the service are protected. Systems must be in place to 24/07/08 ensure that medication is administered correctly and recorded following administration to ensure people using the service receive medication as prescribed. This is an outstanding requirement and enforcement action is now being considered. All staff must receive training in 05/09/08 regard to the specific needs of DS0000002299.V368945.R01.S.doc Version 5.2 Page 26 Requirement 2 OP7 15(1) 3 OP7 15(1) 4 OP7 13(4,c) 5 OP9 13(2) 6 OP30 18(1,a) Clifton Manor Care Home people using the service such as diabetes mellitus, epilepsy and the safe use of bedrails to ensure that people using the service are protected and their needs are met. 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 OP3 Good Practice Recommendations Implement the new preadmission assessment as soon as possible to ensure that clear information in regards to a persons need is available to ensure that staff can fully meet these. Ensure that all complaints received are logged into the complaints book to ensure that an audit trail is easily available to demonstrate that complaints have been dealt with. 2 OP16 Clifton Manor Care Home DS0000002299.V368945.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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