Inspection on 09/03/06 for Clifton Meadows

This inspection was carried out on 9th March 2006.

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 Meadows 20/08/08

Clifton Meadows 04/01/08

Clifton Meadows 16/04/07

Clifton Meadows 02/08/05

Clifton Meadows 17/03/05

Clifton Meadows 03/09/04

Clifton Meadows 26/01/04

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Snydale Care Home

Hawkhills

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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 Unannounced Inspection 12:30 9 March 2006 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 Meadows DS0000003101.V273320.R01.S.doc Version 5.1 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.V273320.R01.S.doc Version 5.1 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 Anchor Trust Janice Linda Scott Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Clifton Meadows is a Care Home registered to care for 65 older people. 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 Anchor Trust. 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. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 9 March 2006, starting at 12.30 hours and finished at 18.00 hours. It included a tour of the premises, conversation with six residents, five members of staff and two members of the Friends’ Group. Care documentation and other records were checked and some aspects of care provision were observed. At the time of this inspection, a training session was taking place in one of the Units of the Home (Solway Lounge), and a number of care staff was in attendance. What the service does well: What has improved since the last inspection? Repair and decoration work have been undertaken to improve the physical environment. There is an on-going refurbishment programme for the Home and this is being implemented. Four new care staff have been recruited and the care staffing level on night duty has been improved. Work is in hand to review the care documentation used at the Home. Training of care staff has progressed well and in particular with regards to ‘Dementia Care’. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 6 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. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 7 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.V273320.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 The information provided by the Home could be improved for the benefit of prospective residents. Assessment of needs of residents, on their admission, remains unsatisfactory and could result in not meeting individual care needs appropriately. EVIDENCE: The Home’s statement of purpose, which is a corporate document (Anchor Homes), has been improved. It now has an insert giving details about the Home. However, there are some omissions in the document and it therefore does not provide some important information, for example the arrangements for dealing with reviews of resident’ s plan and the fire precautions in place at the Home. The care files of two residents, who had been recently admitted to the Home, were checked. They showed that assessments were undertaken by the placing social workers. The assessments undertaken by the Home’s staff, which very often are more up to date and relevant to the admission process, remain poor Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 9 and inadequate. They failed to include important areas of needs and risks, and therefore affected the planning of care in these instances. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. General health and care needs are not always reflected appropriately in individual plans of care, and this practice has a potential to put residents at risks. EVIDENCE: Residents spoken to, commented that they were receiving a ‘good standard of care’. They complimented the staff team for their commitment. They felt that their needs were changing and they were becoming more dependent. They felt that their increased dependency was putting more demands on the limited number of staff at the Home. A sample of assessments and plans of care were examined and found to require improvement in some areas. Care plans did not adequately address identified risks. Actions to be taken to meet care needs are in some instances, still not clear. There was evidence that care plans were not being regularly reviewed. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 11 In discussion, the manager explained that the parent organisation, Anchor Homes, has developed a new care planning system, which is being tried else where in the country. It will be introduced at the Home in due course. The health care needs of residents are being met and there was evidence to this effect. Access to all primary health care services is promoted and facilitated by staff. A medication policy and procedures is available, and all medicines are administered by staff who have received accredited training to do so. However, the medicines administration records (MAR), for two residents who were self medicating, were checked. The two residents, in question, had not been risk assessed for undertaking their self-administration of medicines. In one instance, the resident, who has failing eyesight, was drawing up and selfinjecting her insulin. However, staff had referred the resident to a health care specialist in February 2004, who stated that in her professional opinion, the resident in question was safe to do so. It is advisable that this practice be reviewed. The registered manager must, nevertheless, ensure that all selfmedication of medicines by residents is appropriately risk assessed and the required action taken. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were checked at the previous and were fully met. EVIDENCE: Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were checked at the previous inspection and were fully met. EVIDENCE: Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Clifton Meadows provides a welcoming, well-maintained and homely care setting, with suitable furnishings and decorations to meet residents’ individual tastes. EVIDENCE: The premises are in good decorative condition and there is an ongoing programme of decoration and refurbishment. At the time of this inspection, some refurbishment work was in progress in one of the Units (Wentworth). The ceiling was being fitted with new lights. During the tour of the premises, it was noted that there were building materials, including metal strips along one of the corridors and the main doorway. The work was in progress without putting in place appropriate health and safety measures. This was pointed out to the Home management and the building contractor took prompt action to remove the hazardous materials and also to seal the area where work was being undertaken. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 15 A new bath has been installed and is currently in use by residents. A number of bedrooms have been redecorated. Residents stated that they were satisfied with their individual and communal accommodation. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 There is ongoing training for staff and this ensures that they are equipped to provide as good a standard of service as possible. EVIDENCE: Staff spoken to, confirmed that they receive ongoing training on various topics. There were four new care workers. They had been provided with induction, in line with the ‘Skills for Care’ programme. A number of care staff have received training in the following areas; fire safety, moving and handling, first aid infection control and dementia care. Six senior carers, working across the two units, have undertaken their accredited training on the administration of medicines. Further training is being organised on adult protection for all staff, nutrition and hydration issues and refresher courses in mandatory subjects like, food hygiene, first aid and health and safety. The Home currently employs 39 care staff between the two Units. Only nine are qualified to NVQ level 2 in Direct Care. The manager stated that 15 other care staff were following the NVQ course. On completion of the latter, the Home will be able to meet the requirement of having at least 50 of the care staff trained to NVQ level 2. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 The Home is well organised and well managed for the benefit of the resident group. However a few minor shortfalls are highlighted for action. EVIDENCE: In discussion with the registered manager, it was noted that the Home was managing the personal allowances of 12 residents. In other cases, relatives were responsible for the personal allowances of their loved ones. Some relatives would also from time to time leave some money, with the Home, to give to their loved ones as required. The money is usually kept in individual pouches and records are kept of each resident’ s accounts. A sample of accounts was checked. Income and expenditure were recorded. There were two signatures to witness each transaction. However, in one Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 18 instance, there were no receipts for purchases undertaken on behalf of a service user. Other receipts were not numbered so that they could be tracked. The account was also not in balance, as a small sum of money was not accounted for. There appeared to be a lack of effective audit on the management of residents’ personal allowances. Staff in one of the Unit also stated that they were not able to access residents’ personal allowances’ unless the administrator or the manager was present. It was therefore not possible for residents to access their money as they choose. This practice should be reviewed and appropriate arrangements put in place, for the benefit of the resident group. Residents spoken to, confirmed that they attend residents’ meetings when they are held. They stated that staff and the Home management regularly sought their views. A residents’ satisfaction survey is being carried out and its outcome will be fedback to all participants. The Home has a ‘Friends Group’, which helps out in promoting activities. The group usually works closely with residents and staff to develop its programme. It also ensures that residents’ welfare is safeguarded and promoted. Although the Home has its own quality assurance system to monitor its standards of operation, it is necessary to put in place robust procedures for the auditing of residents’ money and other areas like medicines administration and to report findings and implement action. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 19 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X X Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 20 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 4,5& 12 Requirement The Homes statement of purpose must be improved to meet the regulation. Copies of the document must be made available to this office of the Commission and to other interested parties. (Previous timescale of 14/11/05 not fully met.) Timescale for action 30/06/06 2. OP3 12, 13 & 14 Assessment of care needs must 30/06/06 be improved to ensure that all health, personal and social care needs are considered. The assessment must be in sufficient detail to enable care staff to meet the residents needs, and it must be kept under review and have regard to any change of circumstances and be revised as necessary. (Previous timescale of 28/11/05 not met) Care plans of individual residents must address all identified risks. Care plans must also be appropriately and regularly reviewed. 30/06/06 3. OP7 12, 15 Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 21 4. OP9 5. OP33 6. OP35 The registered manager must ensure that appropriate risk assessments are undertaken for residents who self-medicate. 12, 24 Effective internal audit systems must be put in place to monitor the implementation of agreed procedures in managing residents’ money and administration of medicines. 12, 16, 17 The management of residents’ money must be improved. 12 & 13 30/06/06 30/06/06 30/06/06 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 OP35 Good Practice Recommendations Appropriate arrangements should be made to ensure that residents can have access to their money as and when they need it. Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clifton Meadows DS0000003101.V273320.R01.S.doc Version 5.1 Page 23 - 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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