Inspection on 08/11/07 for Clifton Manor Care Home

This inspection was carried out on 8th November 2007.

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

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

Other inspections for this house

Clifton Manor Care Home 17/04/07

Clifton Manor Care Home 11/04/06

Clifton Manor Care Home 03/05/05

Clifton Manor Care Home 11/02/05

Clifton Manor Care Home 19/04/04

Clifton Manor Care Home 05/01/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clifton Manor Care Home Clifton Manor Care Home Rivergreen Clifton Nottingham NG11 8AW Lead Inspector Karmon Hawley Unannounced Inspection 10:00 8 November 2007 th 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 DS0000026432.V353432.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 DS0000026432.V353432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Manor Care Home Address Clifton Manor Care Home Rivergreen Clifton Nottingham NG11 8AW 0115 984 8485 0115 984 5859 clifton.manor@hotmail.co.uk clifton.manor@hotmail.co.uk Monarch Healthcare Ltd 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) Eileen Teresa Spence Care Home 30 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (30), of places Physical disability (2) Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Clifton Manor Nursing Home is registered to provide accommodation and personal care to people of both sexes whose primary care needs fall within the following numbers and categories:Old age, not falling within any other category (OP) 30 All service users falling within the category of OP must be aged 65 years and over A maximum of 12 beds out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate people over the age of 65 years whose primary care needs are Dementia (DE) A maximum of 2 beds out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate people whose primary care need is Physical Disability (PD) All service users falling within the category PD must be aged 55 years or over One bed out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate a named individual with PD who is under the age of 55 years (See the registration record dated 19/05/06 and the letter dated 19/04/06 within the variation application dated 28/03/06 for the identity of the service user) The communal space on the first floor at Clifton Manor Nursing Home must be used as additional space to that on the ground floor 17th April 2007 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Clifton Manor Care Home (Nursing) is situated in the suburb of Clifton, southeast of Nottingham city and shares a site with its sister home, which provides residential care only. The home was purpose built and the accommodation is over two floors with a vertical lift to provide easy access. There are three lounges used by residents, one of which is designated for people who have Dementia. There is a garden and patio area at the rear of the home but only the patio is useable as the rest of the garden slopes and is not safe. The provider has given assurances that this area will be worked on and completed within the next four weeks to enable the people at the home easy access to outdoors. The home provides personal care and nursing care to up to 30 older people, there are twelve beds, which may be used by people with Dementia, and two may be used for people with physical disabilities. The service complies with its conditions of registration. The fees for the service range from £323.26 to £950 Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 5 per week, the cost varies according to the dependency needs of the resident. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken by an inspector reviewing all the previous inspection records available, looking at information provided by the acting manager about Clifton Manor and by undertaking a visit to the service with the inspector using a method called “case tracking.” “Case tracking” involves identifying individual service users who currently live at the home and tracking the experience of the care and support they have received during the time they have lived there. The inspector also checked that information provided by the acting manager matched individual experiences of the service user living at the home by talking with them and observing the care received. General records maintained by the home were looked at to ensure these were maintained and provided positive outcomes for service users. What the service does well: What has improved since the last inspection? Additional screening has been ordered to ensure that service users privacy and dignity is maintained should they share a room. Work has been undertaken in the garden to ensure that service users are protected from falls or slips down the slope. The storage of wheelchairs has been addressed to ensure that these are not stored in service users rooms, thus ensuring service users personal space is not intruded upon. Clifton Manor Care Home DS0000026432.V353432.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 Care Home DS0000026432.V353432.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 DS0000026432.V353432.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): 2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are assured that their needs will be assessed and that staff can meet these before they decide to move into the home. As the current fees are not documented on individual service users terms and conditions there is confusion in what charges service users may incur. Some of the terms used in the terms and conditions do not consider service users rights. EVIDENCE: To ensure that staff are able to meet prospective service users needs, the manager or a registered nurse, visits them within the community to carry out an assessment prior to admission. There was evidence of this occurring within those case files seen and the most recently admitted service user had been properly assessed before admission. There was a copy of the assessment by Social Care, Housing and Health staff on the file and this had been received by fax before the date of admission indicating that the manager had an opportunity to assess whether a placement at the home would be appropriate. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 10 Prospective service users may also visit the home and spend time there before they make a decision to move in. There was evidence of terms and conditions within those case files seen, however these did not state the cost of the care, nor the cost of any extra services not included in the weekly fees. There had been a concern raised that a charge of £7 an hour was being made for service users to be escorted to out patient appointments. This cost was not made clear within the terms and conditions or the homes Statement of Purpose, therefore people were not aware of this cost. When this was discussed with the manager, she stated that this was discussed verbally with service users and/or their relatives, however there were no records available to evidence this. When reading the terms and conditions of admission, terms which conflicts with what the service is saying within service users charter of rights were observed. These being; medication must be handed into staff and residents are asked to discuss any alcoholic drink requirements on admission and are advised that personal stocks of these items will be held by matron and available on request. Although staff spoken with were not directly involved in the preadmission process they were able to discuss how they were informed of the new service users needs during handover sessions. Intermediate care is not provided at the home and this standard is not applicable. Clifton Manor Care Home DS0000026432.V353432.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 adequate. This judgement has been made using available evidence including a visit to this service. Although minor improvements are required in regard to care planning, service users needs are met. Due to the lack of systems in place to ensure management plans are in place for all identified risks, service users are not fully protected. EVIDENCE: The majority of service users plans of care were personalised and reflected service users needs, however within two plans of care, a number of plans were of a pre-printed nature, which did not reflect individualism. For instance one plan stated to supervise a service user during the self-administration of medication, however they were in fact unable to do this themselves. When a risk to a service user had been identified, management plans were in place within the exception of the following; where one service user was using bedrails the risk of entrapment had not been addressed, thus leaving the service user at a potential risk. In another plan of care where oxygen was in use there was no management plan to ensure service users and staff were protected from potential risks such as explosion when using oxygen. There was evidence of reviews taking place on a regular basis, however within one plan of Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 12 care where there had been significant changes this had not been reflected within the plan of care. On discussing this with the manager and staff they were aware of the changes that had taken place and therefore were offering care as required. There was evidence available within plans of care to show that service users have access to relevant health care service such as, the doctor, dietician, speech and language therapist and physiotherapist as required. The manager stated that good relationships were maintained and services were liaised with when required and any specialist equipment obtained. During the brief tour of the home, there was evidence of specialist equipment in use such as mattresses and cushions to aid comfort and reduce the risk of pressure sores. One service user spoken with said, “I can see the doctor when in need to, I have not long seen the optician.” Staff spoken with were able to discuss the importance of ensuring that relevant equipment was in place to prevent tissue break down. Appropriate policies and procedures are in place for the administration of medication. The registered nurses on duty administer all medication and blister packs are used to reduce errors in medication administration. Medication arrangements were documented within service users plans of care and these were in depth in regard to specialist administration such as administering it through a tube that leads directly into the stomach. Staff spoken with were able to discuss how they ensure that service users privacy and dignity are maintained and gave examples of how they support service users with personal care. Additional screens have been ordered for shared rooms to ensure that services privacy and dignity is maintained whilst receiving personal care. Service users spoken with all stated that staff were very kind and caring and that they felt listened to. One service user said, “the staff are very good, they help me when I need it, they are respectful and care for me as I like it.” Good relationships were observed between staff and service users throughout the visit. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 13 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): 12,13,4 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to participate in activites should they wish and once more are available this will offer service users more choice and variety. Staff understand the importance of maintaining relationships which service users value and ensure that any visitors are welcomed into the home. EVIDENCE: A new activites coordinator is currently being recruited in line with the recruitment policies and procedures. Whilst waiting for the necessary checks to be made a member of staff is currently offering activites to service users. These include activites such as reminiscence; dominoes and old time music and one to one time to spend talking. Outside entertainers such as a band also visit the home on a regular basis. Staff spoken with stated that activites take place in the afternoons and they felt that service users enjoyed these. During the visit a large number of service users spent time sleeping and were not occupied, there was background music playing but no other stimulation. It is felt by the manager that this issue will be addressed once the new activites organiser is in place, as there will be more dedicated time for spending with service users. One service user said, “there are some activites available, however I tend to occupy myself or go out for a walk with my family.” Another said “I enjoy sitting here quietly and watching people that go by the windows.” Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 14 Staff stated that the routine of the home was flexible and service users if able may spend their time as they wish, three service users spoken with confirmed this. There are no restrictions imposed on visiting so that service users are enabled to maintain meaningful relationships with their families and friends. Staff spoken with explained how relatives are supported especially during difficult times when people may be unwell. Staff were observed to maintain good relationships with relatives and also to respond to any requests made. One service user spoken with said that, “I often have visitors and I can see them in private if I want.” To ensure that service users have more choice and control in regards to their personal care there is now documentation within service users files to record their preferences in regard to gender. There are no residents from Minority Ethnic Groups living at the home, though the staff are from a variety of cultural backgrounds and several speak languages other than English. This means the service has the potential to provide a better service to people whose first language is not English. Staff spoken with discussed how they felt it was important to recognise that each service user is different and they have different needs and preferences, they felt that it was essential to spend time getting to know each service user so that they can offer them the care that they want. A wholesome and varied menu is on offer and choices and special diets such as diabetic, vegetarian and soft diets are available at each meal. Service users spoken with said that food was at a good standard and they had plenty to eat. Service users sit in the dining room during meal times and are assisted by staff in an appropriate manner if required. Staff spoken with were able to discuss the importance of ensuring that service users special diets are maintained thus ensuring their personal needs are met. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 15 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. Service users and their family are assured that concerns and complaints will be listened to and acted upon. Systems in place and a well-trained staff team ensure that service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in reception so that relatives and visitors can read it, this is in an easy read format to aid understanding for those service users who may have communication difficulties. The service has received three complaints since the previous inspection, in regard to the standards of care and communication issues. There was evidence available to demonstrate that these had been dealt with and resolved. Staff spoken with were able to discuss how they would deal with a complaint should it be received. All service users spoken with stated that they were happy with the care received and the life within the home. To ensure that staff are aware of their responsibilities and obligations in safeguarding adults training continues to take place. Staff spoken with were able to discuss their personal responsibilities and outlined what they though constituted abuse and how they would deal with it should they suspect that this was occurring. The service currently has a safeguarding issue in regard to the standard of care delivered to a service user on one occasion, the operations manager and the safeguarding adults team are currently investigating this. There are policies and procedures in place for safeguarding Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 16 adults, however this did not cover the procedure to follow when reporting incidents to the safeguarding adults team. This was discussed with the manager and the operations manager, both are fully aware of the procedures they must follow and stated that the policy will be updated to reflect this. Service users spoken with said that they felt settled and safe within the home. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 17 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. Service users live in a comfortable, well-maintained environment, which is clean and tidy. EVIDENCE: A partial tour of the accommodation was undertaken to ensure that the home is clean, safe and comfortable for the service users who live there. A maintenance person is employed who carries out routine maintenance and all areas of the home were well maintained. The lounges are comfortable and pleasant. The garden area has been levelled slightly and the manager said there are plans to continue with the landscaping of the garden, in the meantime the remaining area that has a slight slope has been fenced off to ensure service users remain safe. The storage of wheelchairs has been addressed and following a health and safety assessment an alternative area has been established to ensure that wheelchairs are no longer stored in service users rooms. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 18 All areas of the home accessed were clean and tidy, one service user spoken with said, “the staff always work hard to keep the home clean.” Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. A well-trained staff team are available to meet service user needs. Service users are placed at risk due to the current recruitment policies and procedures taking place. EVIDENCE: The staff rota was inspected to make sure there are enough suitably qualified on duty staff to meet the needs of residents. The rota provided evidence that there are, and staff were observed to assist service users as needed. Staff spoken with said that the staff get on well together and assist each other working as a team. Service users spoken with said that enough staff were available to meet their needs. Six staff have achieved the National Vocational Qualification (a nationally recognised work and theory based qualification) level 2 or above and several staff are working towards completing their training, thus ensuring that service users are supported by suitably qualified staff. Two service users spoken with said that they felt that staff were good and that they were well trained to do their job. To ensure all new staff are aware of their roles and responsibilities and service users needs they undergo an induction, there was evidence of this occurring in those staff files seen and one member of staff spoken with confirmed that they had undertaken an induction when they first started working at the home. They stated that this was good as they had time to get to know service users and their needs. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 20 Four staff files were inspected to make sure that they have the information and documentation required by Law to protect service users from harm or abuse. Only two files contained all the necessary documentation. One file that was for a registered nurse did not contain evidence that their professional identification number was effective, which could mean that this person is not registered to practice. There was also only one reference available, this is not acceptable; two written references must be received before people start work at the home to make sure that service users are properly protected form unsuitable staff. Within the fourth file there was only one reference available, however this member of staff had been in employed with the company for a number of years, this was discussed with the manager, who stated that she would complete a character reference for this person. The staff training records were inspected to make sure that staff have received the training they need to work at the home. There was evidence available to show that training has been provided and staff spoken with confirmed this. Staff have received training in all of the courses required to make sure they work in a safe manner. A number of staff have had training on supporting people with Dementia and further courses in this has been arranged. There was also evidence that the manager and other qualified staff have undertaken training to update their nursing skills. Observations confirm that staff are well trained and sensitive and work safely when service users. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 21 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. Service users live in a home that is well run and managed where they and their family are given the opportunity to express their views and opinions and have these fully considered. EVIDENCE: The manager has been registered by the Commission as a fit person to run the home meaning she is experienced and suitable to do so. She has also completed the registered managers award (a nationally recognised work and theory based qualification), which means she has the required knowledge and skills to carry out her job role. Both the staff and service users spoken with spoke highly of the manager and felt that the home was well run. Quality assurance of the service takes place to ensure this is monitored and service users have the opportunity to express their views. The manager has Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 22 just started holding service user and relatives meetings; the minutes of the meeting were available, which showed that the commencement of the new activites coordinator and standards of care had been discussed. Questionnaires for relatives to complete are also available in the main entrance, several had been returned which offered the following comments; quality of care is excellent, staff respond to call bells quickly, staff knock on doors before entering, staff are very good and there is a welcoming atmosphere in the home. Arrangements for service users finances are recorded within the plan of care to ensure that their interests are safeguarded. There is a facility for service users to have money kept in safe holding in the home. Staff spoken with were able to discuss the arrangements should a service users wish to access their money. One service user confirmed that the home looked after their money and they were happy with this arrangement. There were records available to show that staff now undertake regular supervision session with the manager. Supervisions cover such aspects as personal development and standards of care. Staff spoken with said that they felt that the supervision sessions were of benefit and they had the opportunity to discuss service users needs. Staff have received training in health and safety and staff spoken with were able to discuss how they ensure this is maintained in their daily practice. Staff were observed to maintain good practice throughout the visit. There were no hazards evident during the brief tour of the home. Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 23 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 12(2,3) Requirement The terms and conditions should so far as practicable reflect that service users are enabled to make decisions and choices in respect to the care they are to receive and their health and welfare to ensure their rights are maintained. The terms and conditions must outline the exact cost of care and any additional costs that may be incurred to ensure service users are fully informed thus able to make an informed decision as to whether they accept these terms. Following reviews, plans of care must be updated to ensure that service users current needs are fully reflected and met. Appropriate systems must be in place to ensure that all risks are highlighted and managed thus ensuring that service users are fully protected. Following consultation plans of care must be personalised to ensure that their personal needs and preference are fully DS0000026432.V353432.R01.S.doc Timescale for action 20/01/08 2 OP2 5(1,b) 12/01/08 3 OP7 15(2,b) 20/12/07 4 OP7 13(4,c) 20/12/07 5 OP7 15(1) 15/01/08 Clifton Manor Care Home Version 5.2 Page 25 6 OP18 13(6) 7 OP29 19(1,a,b,i ) schedule 2 18(3,a) 8 OP29 addressed and met. Measures must be taken to ensure that clear guidance is available for all staff for the recording and referral of incidents to the safeguarding adults team to ensure that service users are fully protected. Staff personnel files must contain all the required documentation to ensure that service users are protected. Evidence to demonstrate that registered nurses professional identification number is effective must be available to ensure that service users are fully protected. 20/12/07 20/12/07 08/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clifton Manor Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000026432.V353432.R01.S.doc Version 5.2 Page 27 - 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!