Inspection on 19/10/05 for Clough House

This inspection was carried out on 19th October 2005.

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

Clough House 08/05/07

Clough House 31/08/05

Clough House 03/11/04

Clough House 19/05/04

Clough House 25/11/03

Clough House 22/05/03

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

CARE HOMES FOR OLDER PEOPLE Clough House 7 Worden Lane Leyland Lancashire PR25 3EL Lead Inspector Pauline Randles Announced Inspection 19th October 2005 9.30 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 Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clough House Address 7 Worden Lane Leyland Lancashire PR25 3EL 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) 01772 436890 Clough House Residential Home Limited Mrs Michelle Florence Darwen Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 14 service users in the category of OP (Old age not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 31st August 2005 Date of last inspection Brief Description of the Service: Clough House is a residential home providing personal care and accommodation for 14 older people of both sexes aged 65 or over. The home is one of three owned by Mr and Mrs Cairns. The home is situated in a conservation area in Leyland close to local shops and other facilities and is on a main bus route. Accommodation is provided on two floors with twelve single rooms and one shared room. The first floor is accessed by two stair lifts sited at each end of the building. Communal rooms are all sited on the ground floor. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Clough House was announced and took place over a period of five hours. There were fourteen residents living at the home on the day of inspection. The registered provider, administrative manager, registered manager; four residents, two relatives and four members of staff were spoken to. During the inspection records and procedures were examined and lunch was taken with residents. Ten comment cards completed by residents, six from relatives and a pre inspection questionnaire contributed to the findings of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The planned relocation of the laundry and installation of a sluice will improve laundry facilities for the benefit of residents of Clough House. The completion of the installation of suitable locking facilities on all bedroom doors will provide residents with a real choice of whether to lock their room or not and provide additional privacy and security. To improve effectiveness in Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 6 achieving work force training targets and ensure continuing competence and motivation of staff a minimum of three days paid training a year should be provided. The registered manager should achieve National Vocational Qualification Level 4 in management and care by 2007 in order to further develop her skills and knowledge and to evidence that she has the standard of competence required to manage a care home. 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. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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 Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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 The Statement of Purpose and Service User Guide provides service users and their representatives with full details of the home’s services and facilities enabling an informed choice to be made about possible residency. EVIDENCE: The Statement of Purpose and Service User Guide continue to meet the requirements of the standard providing details of services and facilities on offer at the care home. This level of detail enables a prospective resident to make an informed choice about future residence at Clough House. Both documents were reviewed in June 05. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 9 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, 8, 9 and 10 Plans of care are detailed, reflecting assessed needs and providing staff with appropriate guidance on individual care service provision. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. Medication procedures are thorough and underpinned by professional guidance to promote good practice. Personal support in the home is provided in a manner that supports the privacy and dignity of the residents promoting their independence. EVIDENCE: The service user plan of care detailed all aspects of health; personal and social care needs of the individual. The care plans were readily accessible to staff and had been updated daily. Since the previous inspection the care plan reviews had been signed by the resident concerned to confirm their agreement to the review outcome. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 10 In speaking to three of the residents it was noted that they’d had some recent individual health concerns. These health concerns, the response and the outcome were fully recorded on the individual files of the residents evidencing that health matters were promptly and effectively addressed. One resident who had particular health difficulties said, “Care staff look after me beautifully.” As previously recommended the medication procedure had been reviewed against the professional guidelines of the Royal Pharmaceutical Society to ensure continuing compliance with best practice. Staff members described methods used to support the privacy and dignity of individuals, for example by providing privacy when toileting or bathing a resident and by knocking when entering a bedroom. One resident said, “Staff wait to be invited in” whilst a visitor said, “we are always made welcome and privacy is available if we need it.” Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 11 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): 14 and 15 Personal support and services provided by the home ensure that residents are enabled to exercise choice and that independence is maintained. Meals of a high quality are produced that are appealing and aid the health and nutrition of residents. EVIDENCE: Residents, or their representatives, deal with personal financial or legal transactions. From discussion with staff, observation and examination of the resident’s charter of rights, it was clear that residents are empowered to make choices and take control over their daily living arrangements. One resident confirmed this to be the case in practice when she said, “anything I want, gets done”. Information relating to advocacy services was freely available to enable residents to access support independently of the care home as required. Residents had sight of their personal records through their involvement in the review of risk assessments and care plans as evidenced by their signature to these processes. Residents expressed high levels of satisfaction with the meals provided. Comments made included, “ meals are very good” and “if there is something I Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 12 don’t want they will always substitute something else.” Also one resident said, “we get plenty of drinks.” Menus indicated that meals are balanced and nutritious. Discussion with the cook on duty and examination of records confirmed that temperature checks and kitchen cleaning schedules were effectively maintained. The dining room is suitably furnished and has a homely ambience. On the day of the inspection residents were observed to enjoy their lunchtime meal. Support appropriate to individual needs, for example assistance for a resident who has a visual impairment was sensitive and enabling. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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): 16 The complaints procedure is consistent and includes clear information provision for service users to enable them to raise any concerns with confidence that these will be listened to and acted upon. EVIDENCE: The policy and procedure for dealing with complaints is clear, consistent and in keeping with requirements. Staff members demonstrated an understanding of the policy and were clear about their role in activating the procedure. There is a culture of openness in the home. Residents spoken to, felt confident that managers would respond positively to any concerns. One resident said, “ I’ve been here nine years, wouldn’t go anywhere else” whilst another said, “I can’t find any fault with the girls.” Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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): 21, 24, 26 Residents have sufficient and suitable lavatories and bathing facilities to ensure their personal care and hygiene needs are adequately met. The rights of residents to be private and secure, when they so choose, will be enabled through the completion of the installation of suitable locking facilities to all bedroom doors. The environmental standards are good providing residents with a clean and hygienic home in which to live. EVIDENCE: There were five toilets, two bathrooms and one shower facility available for the use of fourteen residents. Toilets were clearly marked and were available close to dining room, lounge and bedroom areas for the convenience of residents. Laundry facilities are sited in the basement at present. There are plans in place to build an extension to the home that will include a separate laundry and Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 15 sluice facility. In the interim the manager advised that the incidence of soiled laundry was rare and explained the system that was in place to deal hygienically with soiled laundry should the need arise. Locks with a suitable override facility are being fitted to all bedroom doors as previously recommended to provide residents with a real choice of whether or not to hold a key, subject to a risk assessment. The home was clean and hygienically maintained at the time of inspection. Control of infection procedures and cleaning schedules for day and night care staff and domestic staff were examined and found to be thorough taking into account all aspects of cleaning to ensure the care home continues to be a healthy place to live and work. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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): 27, 29 and 30 The numbers and skills mix of staff provides good levels of care to meet the various assessed needs of residents. The recruitment and selection procedures ensure that candidates with suitable skills and qualities are appointed to work in the care home. The induction and foundation training programmes provide new staff members with the means to train to the appropriate level of competence required for their care duties. EVIDENCE: The home is staffed in accordance with requirements of the previous regulatory authority whilst taking into account the dependency needs of residents. Discussion with staff and residents, examination of staffing rotas and observation indicated that the present skills mix and qualities of staff effectively meets the assessed needs of residents. One resident said, “ I have only to touch the bell during the night and staff respond promptly”. As previously recommended the employment application form had been reviewed and revised to improve compliance with equal opportunity and disability discrimination legislation. A reviewed form is currently in use and a further revision is being undertaken which will result in the production of an employment application and an employment monitoring form. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 17 Training records confirmed that there remains a strong commitment to the provision of mandatory, specialist and national vocational qualification training for all staff. Staff members had continued to undertake training in their own time. It therefore remains a recommendation that a minimum of three paid training days a year be provided to ensure ongoing commitment and motivation of staff to the range of training opportunities available. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 18 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): 31, 33 and 35 The management team provide clear leadership and guidance throughout the home that enables staff to fulfil their roles competently. The culture of openness within the home and the use of formal quality assurance systems enable and encourage feedback as to how well the service is doing in meeting the needs of residents. The financial interests of residents are safeguarded by the policy and procedures of the care home. EVIDENCE: Discussion with the registered manager, and examination of the manager’s role definition, confirmed an understanding of the responsibility and line of accountability associated with the role and an ability to undertake the task competently. When asked about the standard of management within the care Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 19 home one resident described management staff as “being there for you”, whilst another resident said they are “wonderful.” The registered manager had commenced the Registered Managers Award and was aware that she should complete national vocational qualifications at level 4 in management and care by 2007. There are two formal independent quality assurance systems in place at Clough House. A recent survey the home had conducted, that had involved residents and their relatives, had resulted in a 100 response rate with 97 customer satisfaction recorded. Policies and procedures had been reviewed at appropriate intervals to ensure compliance with changes in legislation and reference to the National Care Standards Commission had been amended as previously requested. All residents, apart from one gentleman, hold full responsibility for their own finances. In the instance where limited support was provided, a written record of transactions had been maintained. Secure facilities are available should any resident require money or valuables to be held for safekeeping. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 20 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 N/A 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 N/A N/A N/A 2 N/A N/A 2 N/A 3 STAFFING Standard No Score 27 3 28 N/A 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 N/A 3 N/A 3 N/A N/A N/A Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action 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 2 3 4 Refer to Standard OP21 OP24 OP30 OP31 Good Practice Recommendations A sluice facility should be provided. All private rooms of residents should be fitted with suitable locks and each resident should be provided with a key subject to the outcome of a risk assessment. Staff should receive a minimum of three paid training days per year. The registered manager should achieve a qualification equivalent to NVQ Level 4 in management and care by 2007. Clough House DS0000005915.V252000.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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 Clough House DS0000005915.V252000.R01.S.doc Version 5.0 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. 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. 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