Inspection on 16/04/07 for Clifton Meadows

This inspection was carried out on 16th April 2007.

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

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

Other inspections for this house

Clifton Meadows 20/08/08

Clifton Meadows 04/01/08

Clifton Meadows 09/03/06

Clifton Meadows 02/08/05

Clifton Meadows 17/03/05

Clifton Meadows 03/09/04

Clifton Meadows 26/01/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clifton Meadows Badsley Moor Lane Rotherham South Yorkshire S65 2BA Lead Inspector Ramchand Samachetty Key Unannounced Inspection 09:00 16th. April 2007 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 Meadows DS0000003101.V329272.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 Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Meadows Address Badsley Moor Lane Rotherham South Yorkshire S65 2BA 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) 01709 838639 01709 838913 jan.scott@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Janice Linda Scott Care Home 65 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (40) of places Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: Clifton Meadows is registered to care for 65 older people, 40 of whom being in the category of old age and 25 older people with dementia. It is owned and managed by Anchor trust, which is a national voluntary organisation providing a range of services for older people. The Home is situated in the residential area of Clifton, within easy reach of Rotherham town centre and other leisure facilities, including Clifton Park and Herringthorpe playing fields. The Home consists of 2 two-storey buildings, adjacent to each other. It also shares its premises with some units of sheltered accommodation, which are provided by its parent organisation, Anchor Trust. One of the buildings (Wentworth Lounge) has been specifically redesigned to provide a service for people with dementia. All residents bedrooms are single and have en-suite facilities. Bedrooms and some communal facilities are grouped in smaller units to facilitate group living. Each building is equipped with a kitchen, a laundry, dining areas, lounges and a range of hygiene facilities. Meals are prepared in only one of the buildings and it is transported to the other building in a heated trolley. There is a passenger lift in each building to facilitate access between the floors. There are some garden areas and car parking spaces around the Home. The home has produced a statement of purpose and a service user guide. The current scale of charges range from £324.00 to £397.00 per week. Further information can be obtained from the home. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 16 April 2007, starting at 09.00 hours and finished at 18.30 hours. The home is registered to provide accommodation and care for up to 65 older people, over two units. There were 61 people in residence at the time of this inspection. The person in charge of the service was the deputy manager, Ms Sheila Evans. All the key national minimum standards for ‘Care Homes for Older People’ were assessed and compliance with the requirements and recommendations of the previous inspection was discussed. The inspection included a tour of the premises, examination of care documents and other records, which included medication, complaints, and staff files, conversations with six residents, five members of staff and four visitors. The care of two people who use the service was tracked and some aspects of care provision were observed. As part of the pre-inspection planning, notifications and other relevant documents, including the pre-inspection questionnaire, were looked at. Five comment cards were sent to the home for distribution to people living there. None of these comments cards were returned. The inspector would like to thank all the residents and their visitors, in particular the members of the ‘gardening club’, staff and managers who helped with the inspection. What the service does well: People who use the service and their relatives were satisfied with the care being provided at the home. They commented that the accommodation was excellent and that the care staff were “hard-working, kind and very committed”. Staff and management have a good relationship with the resident group. This relationship is based on respect for the individual and for their rights. There is also good communication among them. The accommodation and the facilities at the home continue to be of high standard and are well appreciated by people who use the service. The meals service is well organised and well liked by the residents. People living at the home were proud of their association with the local community and with their own “Friends of Clifton Meadows” group, which assist them with a range of recreational activities. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The statement of purpose needs to include a copy of the home’s complaints procedure. Although new care planning documentation has been developed, there is a need to ensure that people who use the service are provided with a care plan as soon as it is practical, so that care staff have adequate guidance on how to meet care needs, including potential risks, of each person. Staff and management need to review and improve the provision of social and recreational activities, with regards to the needs and capabilities of residents, in particular those with dementia. The number of care staff deployed on duty, especially during daytime in the unit for dementia must be improved to ensure that the needs of the resident group are effectively met. There is a need to ensure that the recruitment and selection procedures are appropriately carried out in order to continue protecting the safety and welfare of people who use the service. The complaints procedure and the quality monitoring tools must be more robustly implemented to ensure that the service can benefit from their outcomes. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 7 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 Meadows DS0000003101.V329272.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 Meadows DS0000003101.V329272.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): 1 and 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service and those who were interested to use it, were given sufficient information to help them in making their choice. Assessments of needs were carried out before people were admitted to the home, to make sure that their care needs could be met. EVIDENCE: The statement of purpose and service user guide had been revised to include information on the provision of care to dementia sufferers. These documents were available to all people living and those who would like to live at the home. Although the home has a complaint procedure, this was not included in Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 10 the statement of purpose. The statement of purpose could be provided in different formats, if requested. The service also had use of two brochures, which gave information about the parent organisation (Anchor Homes) and its local and country- wide services. Care plans showed that people were admitted to the home after their needs had been assessed. These assessments were carried out by placing social workers and by the home staff. Assessments for people, who fund their own care, were carried out by senior staff. Clifton Meadows DS0000003101.V329272.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. People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence, including a visit to this service. People living at the home were satisfied with the care and support they were receiving, which they felt was helping them in their daily activities of living. Although the care planning system was on the whole, being improved, there were some shortfalls, which could lead to inadequate and inappropriate care being given. The management of risks for people using the service was inadequate and this could affect their safety and welfare. EVIDENCE: People who use the service and their relatives were satisfied with the care being provided at the home. They commented that “the care was good and the care staff were hardworking and friendly”. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 12 People living at the home said that staff treated them with respect and observed their privacy at all times. This practice was evident during the inspection. In general people who use the service were provided with care plans, which specified the actions that were to be taken to meet their care needs and to manage the risks they faced in their daily living activities. However, three persons had no care plans in place. They had been admitted in the last few weeks. This meant that care staff had no guidance in how the needs and risks of these persons should be catered for. A new care planning and recording system has now been introduced at the home and each person living at the home will be provided with a new care plan. However, only one member of staff had been trained on the new care plan to date and other members of the staff team were unsure about the management of this change in care planning. The care files which were checked, showed that people living at the home, had been appropriately registered with a local GP surgery. Care plans also showed that risks were not consistently and appropriately identified and managed. This practice could potentially put people using the service at risk. People living at the home had good access to health care professionals, including district and community psychiatric nurses. However, a few relatives commented on the difficulty that their loved ones often experienced, in accessing the services of an NHS chiropodist. A medication policy and procedures was available to ensure appropriate management of medication at the home. Staff who administered medicines had received accredited training to do so. There were three people who were administering their own medicines but only two of them had a risk assessment to make sure they were safe to do so. One of the risk assessments was nearly two years old. The receipt, storage and recording of medicines were checked and found to be satisfactory. Clifton Meadows DS0000003101.V329272.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 to 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service were generally satisfied with the daily routines at the home but some of them said that their ability to make choices was being curtailed. This was starting to affect the quality of care they were receiving. Although social and recreational activities were organised at the home, these were not always accessible to people who were frailer or who suffered from dementia. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 14 EVIDENCE: Social and recreational activities in one of the units (Solway lounge) were organised principally by a group of volunteers, “ Friends of Clifton Meadows”. One of their aims was to raise funds for the residents’ group. A list of events for the year 2007 was available and it indicated that there would be events both in the unit and in the community almost on a monthly basis. People living in this unit together with a few relatives had also set up a “gardening club”. A number of people using the service said that they were happy with the activities and that they could join in, as they wanted. Two persons said that they were looking forward to do some flower potting, as the weather was getting warmer. In general, care plans included some information on how people using the service liked to spend their daytime. They were given an opportunity in residents’ meetings to express their views on the activities programme. However, some people living at the home said they were often incapable of joining in the activities and events that were organised. In the unit for dementia sufferers, there was a dedicated part-time activities coordinator, who had the responsibility of organising social and recreational activities for the people living in the unit. However, on the day of this inspection, except for the coffee morning, there were no other planned activities. People using the service were observed sitting in the lounge or in their rooms. Staff said that the coordinator was on holiday. Staff said that they did not have enough time to sit and talk with residents on a one to one basis, and to give what the service has termed “quality time”. Relatives also confirmed that staff were “too busy to be able to give time” to their loved ones. Relatives commented that they were welcomed at all times. Some people using the service were happy that they had been able to attend events, such as theatre and fairs, within the wider community with assistance from care staff and volunteers. Some people using the service said that they found daily routines to be flexible. Others commented that they were less able to exercise choice in some areas. Examples included, an individual having just one bath day a week and the inability to order sandwich fillers but to choose from assorted sandwiches for afternoon meal. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 15 People living at the home were satisfied with the cooked meals. The main meal was served at lunchtime. The menu contained two main choices and an alternative if required. The protein part was plated and vegetables were served in tureens to allow each person to take the amount they wanted. Drinks and snacks were also available between meals. Meals for people, who live in the unit for dementia, were transported there by a motorised trolley. Special precautions were taken to make sure the food was still hot and appetising when it was served. Clifton Meadows DS0000003101.V329272.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. People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There was a complaints procedure in place and people using the service and their relatives knew how to use it. However, the management of individual complaints was not in line with the procedure and was unsatisfactory. Complainants were therefore uncertain whether issues raised were being addressed. Staff had knowledge and understanding of adult protection issues and were able to safeguard people in their care. EVIDENCE: There was a complaints procedure in place and it gave information on how to make a complaint and who would deal with it. People using the service said that they were aware that they could complain if they had reason to do so. Relatives also confirmed that they had been informed of the complaints procedure. However, one relative said they had complained to the deputy manager (Wentworth Lounge) about an important care issue. She had not been informed about the outcome but presumed that the matter had been resolved. Senior staff said they were not aware of this complaint and there was no record of it. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 17 The deputy manager (Solway Lounge) stated that they had received two other complaints since the last inspection. However, complaints records showed investigation details of only one of the complaints. An adult protection policy was also available to promote the safety and welfare of people living at the home. Staff had been trained on adult protection and were aware of the relevant procedures. There had been two referrals to the adult protection team of the local social services department and no information has yet been received. Clifton Meadows DS0000003101.V329272.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, 22 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the standard of accommodation and with the opportunity to personalise their private accommodation to make it their own. EVIDENCE: People living at the home were satisfied with the standard of accommodation. They said the buildings were clean, comfortable and pleasant. They were able to personalise their bedrooms with their own furniture and memorabilia. However, it was noted that the seating arrangements for some people caused Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 19 them to be some distance away from the staff call bells. This was particularly unhelpful where the individual had mobility problems. The premises were in good decorative condition. Staff stated that the unit for people with dementia had been decorated according to good practice on issues regarding the physical environment for dementia care. Different colours were used to assist people with dementia to locate various areas. The unit for people with dementia had been provided with security keypads on the main doors. The manager of the sheltered scheme, which is also operated by the provider, stated that a small number of the tenants still had to access the unit to do their laundry. It had been agreed that this arrangement would be brought to an end, once the service for people with dementia commenced. The internal premises were clean, tidy and pleasant. There was one bedroom, which had persistent malodour and the carpet appeared stained. A domestic stated that the carpet was regularly cleansed. The communal areas were provided with good standard of furniture and fittings. The grounds surrounding the unit for dementia contained a secure garden and a patio at the back. The grounds surrounding the other building were well maintained and members of the gardening club had been involved in planting shrubs and flowers to make the place pleasant. The handyman was arranging for outdoors furniture to be placed in the garden areas of both buildings. Clifton Meadows DS0000003101.V329272.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 to 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although people living at the home said that they were, in general, receiving a good standard of care, the staffing level was not consistently sufficient to meet needs. This left a number of people, in particular those with dementia, without the opportunity to benefit from individual staff time on a one to one basis. There were shortfalls in the staff recruitment and selection procedures, which could potentially lead to inappropriate staff being recruited. Although staff were satisfied with the training they were receiving, the supervision arrangements were inadequate and this could affect staff performance and development. EVIDENCE: Each of the two units of the home had its own dedicated staff team, including a deputy manager. On the day of this inspection, the unit for people with dementia (Wentworth Lounge) had 22 residents. There was one team leader and two care assistants on duty. The team leader was mostly busy dealing Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 21 with telephone enquiries and with administering medicines. The two care assistants were providing care. One additional care assistant had been requested to come in for two hours, to assist with the planned coffee morning. The deputy manager was on leave but she came in to assist with the inspection. In the afternoon there were only two care assistants and a senior carer scheduled to work on this unit. Two care assistants were also rostered to work the night shift. Staff stated that a number of people living at the home required two members of staff to move and handle them and therefore a number of care tasks were taking a long time to be done. They also added that the senior carer on duty was always dealing with telephone enquiries and with administering medicines. One care assistant stated that most of the care assistants had to “rush from person to person” to make sure their calls were answered and their needs met. They added that the situation was made worse when staff were on sick or on leave. Staff also confirmed that they had to undertake some non-care duties like cleaning and putting residents’ laundry away. Relatives confirmed that staff were always “very busy” and had no time to sit and talk to their loved ones. This was evident during the inspection, when a number of persons using the service was observed sitting in their own rooms, very often away from their staff call bells or in the lounges with very little social stimulation. There was a part-time, dedicated activities coordinator but she was on leave. There were 39 people in residence in the other building (Solway Lounge). There were four care assistants and a team leader on duty during daytime hours and three care assistants on night duty. However, this unit was arranged in four wings of 10 residents each. One care assistant was deployed to work on each wing during the day. They were required to summon help from other colleagues when they had to deal with people who required two care staff to move and handle them. People living at the home stated that they were concerned about the staffing level and had asked for more staff at residents’ meetings but the manager had stated that the service was operating within guidelines. It was noted that a number of social and recreational facilities were organised and carried out by volunteers of the ‘”Friends of Clifton Meadows” group and in so doing helped with the issue of staffing. The files of three newer care staff were checked to assess the home’s staff recruitment and selection policy. The home had an equal opportunities policy and monitored relevant diversity and equality issues. However, it was noted Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 22 that the current workforce had only one male member of staff and did not reflect the local population mix in terms of ethnicity. The staff files showed that in one instance, only one written reference was obtained for a care assistant. There was no interview notes, except for answer record tick list. In two cases, there were no CRB disclosures but POVA Checks had been carried out. In one instance the member of staff, without a CRB disclosure, was deployed in the unit for people with dementia and was therefore inadequately supervised due to the shortage of staff. It was not possible to verify that all other staff and volunteers at the home had undertaken their CRB checks as the relevant documents were kept at the Human Resources Department of the parent organisation (Anchor Homes). Training records showed that a number of training topics had been undertaken by care staff since the last inspection. These included dementia care, adult protection, moving and handling (Back care), health and safety, fire precautions and fire drills, food hygiene and the end of life care. Care staff were satisfied with the training they were receiving. Nine care staff had achieved their NVQ level 2 in care and seven others were currently working towards this qualification. A few care staff said that they were hoping to study for this qualification. Whilst care staff were receiving regular supervision, the deputy managers and some team leaders had not been supervised as required. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 23 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, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home was well managed to ensure the safety and welfare of people who live there. However, quality monitoring and quality assurance methods were not being appropriately used. This could result in an overall lack of service improvement. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has worked for the organisation for 20 years and was experienced in the care of the elderly. She has achieved her “Registered Manager Award” and has a qualification in Social work. People using the service commented that she was managing the home well and that she provided good leadership to the staff team. Senior staff stated that the parent organisation (Anchor Homes) had its own internal quality monitoring system but they did not know enough to comment on it. One deputy manager explained that Anchor had sent a satisfaction questionnaire to relatives and visitors. There were also satisfaction questionnaires for residents but there was no indication as to when they were sent out and when they should be returned for comments to be considered. In both cases, no outcome was available. There was no indication that any internal quality monitoring tools and audit systems were being used in a consistent manner. This was a requirement at the previous inspection. Some people living in the Solway unit said that they made sure they attended any residents’ meeting that was called in order to express their views and to help improve the service. However, these meetings were not being held regularly enough and had not been held in the unit for people with dementia. Senior staff said that the operations manager visited the home on occasions and produced a monthly report (Regulation 26 reports), but these were not available at this visit. Staff were assisting up to 22 residents with the management of their personal allowances. Their money was deposited in a no-interest account to which four senior members of staff were signatories. Separate accounts were kept for each person, together with receipts to evidence any financial transactions. Some “petty cash” was kept and made accessible to residents as required. The registered manager had submitted details of all recent maintenance checks of appliances and equipment in use at the home. These included the passenger lifts, the hoists and the utilities. Staff stated that fire equipment and fire alarm were checked regularly and that they had received fire training. Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 Requirement The Homes statement of purpose must be improved to include the complaints procedure. Timescale for action 25/06/07 2. OP7 12 Care plans must be appropriately 25/06/07 developed for all people using the service, and they must be regularly reviewed. (Previous timescale 30/06/06 not met) Appropriate risk assessments must be undertaken for people who administer their own medicines. (Previous timescale of 30/06/06 not met). Appropriate social and recreational activities must be organised in line with the needs, capabilities and preferences of people who suffer from dementia. All complaints received must be appropriately acknowledged, investigated and resolved with each stage being recorded. 25/06/07 3. OP9 12 4. OP12 16 25/06/07 5. OP16 22 25/06/07 Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 27 6 OP22 23 7. 8. OP26 OP27 16 18 9. OP29 19 10. OP33 24 11 OP36 18 People living at the home must be provided with access to staff call bells, in particular when they are in their bedrooms during daytime. The identified room must be appropriately cleansed to make it free of offensive odours. The number of care staff deployed on the unit for people with dementia, must be increased by at least one during daytime hours, in order to effectively meet their needs. A review of the level of care staffing in the Solway Unit must be carried out to ensure that care interventions with regards to ‘double handlers’ can be effectively carried out. The recruitment and selection procedure must be improved to ensure that all applicants supply two written references and appropriate CRB disclosures. Where staff are checked against the POVA list first, they must be effectively supervised when they are working at the home. Effective internal audit and quality monitoring systems, which include the views of people using the service, must be consistently implemented and their outcomes made available. Regular supervision must be provided to all grades of care staff working at the home. 25/06/07 25/06/07 25/06/07 25/06/07 25/06/07 25/06/07 Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 28 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 Good Practice Recommendations Clifton Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Meadows DS0000003101.V329272.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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