Inspection on 31/08/05 for Clough House

This inspection was carried out on 31st August 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 19/10/05

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 Unannounced 31 August 2005 09:15 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 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 F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Clough House Address 7 Worden Lane Leyland Lancashire PR25 3EL 01772 436890 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Clough House Residential Home Limited Mrs Michelle Florence Darwen Care Home 14 Category(ies) of OP - Old age (14) registration, with number of places Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 14 service users in the category of OP (Old age not falling within any other category). 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3. 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. Date of last inspection 3 November 2004 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 F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Clough House was unannounced and took place over a period of six hours. There were fourteen service users living at the home on the day of inspection. The registered provider, administrative manager, four members of staff, nine service users and a visiting chiropodist were spoken to. The registered manager was not on duty at the time of this inspection. During the inspection the premises were viewed, records and procedures examined, lunch taken with service users and social activities observed. What the service does well: What has improved since the last inspection? What they could do better: Improved clarity of the medication policy would be achieved if the policy was revised to incorporate the additional medication practices and a review of the policy was undertaken against professional guidelines. The employment application form should take into account equal opportunity and disability discrimination requirements to ensure best practices are adhered to. Confirmation that the service user had been involved in their review of care would be more readily evident if they were invited to sign the review Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 6 document. The planned relocation of the laundry and installation of a sluice will improve laundry facilities for the benefit of service users at Clough House. The recommended installation of suitable locking facilities on all bedroom doors will provide service users with a real choice of whether to lock their room or not and provide additional privacy and security. To improve effectiveness in 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. 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 F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 standard(s) 2 and 3 The needs of service users are fully assessed prior to admission. A place is only provided at Clough House if care needs can be met and if the service user agrees to and accepts the terms and conditions of occupancy as detailed in the written contract. EVIDENCE: Terms and conditions of occupancy had been amended as recommended following the previous inspection. To ensure clarity of information the document now specifies that nursing care is not provided at Clough House although it can be provided at a sister home that is registered to provide nursing care should the condition of a service user deteriorate. All new service users had been issued with the terms and conditions of their occupancy when admitted to the care home. Needs assessments that had been carried out prior to admission were thorough and comprehensive and included general risk assessments and assessment of daily living activities to ensure that appropriate levels of care could be provided if the service user chose Clough House. One service user said “ Mrs Cain came to see me in hospital before I came here” whilst another service user said “ I Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 9 came for a fortnight to see if I liked it and never went home.” Service users that had been admitted following a local authority care management request had the local authority needs assessment and care plan on file which provided additional background information. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 standard(s) 7 and 9 Plans of care are detailed, reflecting assessed needs and providing staff with appropriate guidance on individual care service provision. A review of the medication policy will strengthen practice through an improvement in clarity and reference to professional guidance. EVIDENCE: The service user’s plan of care had been drawn from the original assessment of need and included information relating to personal hygiene, mobility, health, social and emotional care, and preferences that enabled suitable provision of support services. A daily report of the support provided had been maintained to ensure any change to the care needs of service users was identified. The care plans had been reviewed monthly. The reviews had been signed and dated by the reviewing officer and there was evidence from discussion that service users had been involved. It was noted that in some cases the service user had signed the review of the general risk assessment but not the review of the care plan. To evidence agreement from the service user to the outcome of the care plan review it was recommended that they, or their representative, be asked, where practicable, to sign the care plan review document that incorporates all aspects of reassessment. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 11 Medication procedures and practices had been developed and extended as previously required following a pharmacy inspection. However the additional procedures had not been incorporated into the policy and there was no evidence that Royal Pharmaceutical Society guidelines had been accessed in order to keep the policy under review. To ensure compliance, greater clarity and ongoing safety in administration of medication it was recommended that a review of the policy take place. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 standard(s) 12 and 13 The lifestyle needs and preferences of service users are met at Clough House and their right to maintain chosen contacts with family and friends is upheld. EVIDENCE: A range of activities is on offer to meet group and individual preferences and assessed need. More than one service user spoken to said they were “happy with activities.” Some service users were observed to be quietly listening to music or television in their rooms whilst others had returned from a walk with a member of care staff. An activities list was clearly on display on the notice board by the service users’ lounge. Staff members said “when we have time we get involved in dominoes, manicures and taking people out for walks.” Another member of staff said that service users “sit out quite a lot in the nice weather”. The visitors’ policy is clearly laid out in the statement of purpose for the home. Staff when interviewed demonstrated a clear understanding of the policy and an appreciation of the rights of a service user to choose whom to see or not see. The registered proprietor was observed to ask service users, in private, if they were willing to meet and speak with an inspector in their room before allowing access. Service users spoken to said that their visitors were “always made welcome, and offered a cup of tea.” Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 standard(s) 17 and 18 The legal rights of service users and their protection from abuse is upheld by the policies, procedures and systems in place at Clough House. EVIDENCE: The previous recommendation to provide advocacy information had been addressed. For the benefit of service users, their visitors and staff members, information leaflets about two locally available services have been prominently displayed on notice boards. This information will empower service users to seek an independent voice should they so wish and to have their legal rights protected. The adult protection procedure is detailed, makes reference to Department of Health guidelines and includes dealing with physical or verbal aggression and whistle blowing. Staff members when spoken to were clear about whistle blowing procedures. One staff member said she would have “no hesitation about taking concerns as high as necessary” and she would have “no tolerance of any inappropriate behaviour.” It is recommended that the reference to National Care Standards Commission, in the procedures, be amended to read Commission for Social Care Inspection to ensure that staff members at all levels are clear about whom to approach. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 standard(s) 19, 21 and 24 The premises are suitable for the purpose, well maintained with sufficient toilet and bathing facilities and private accommodation that is comfortable and furnished to meet personal requirements. The rights of service users to be private and secure, when they so choose, would be enabled through the installation of suitable locking facilities to all bedrooms. EVIDENCE: The home is accessible, suitable for the purpose and well maintained. Bedrooms have been appropriately furnished, decorated and personalised to meet individual requirements. Service users spoken to were happy with their rooms and the visiting chiropodist said she found service users to be “comfortable and well cared for, in a home from home.” Locks had not been fitted to all bedroom doors. The proprietor explained that this was a matter of choice for individual service users. Whilst accepting that service users have a right to choose whether or not to lock their door it Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 15 remains a recommendation that locks be installed as without a locking facility a realistic choice of whether or not to hold a key cannot be made. The staff member who deals with maintenance attends the home each week to attend to any maintenance tasks arising and records confirmed that any such matters had been attended to effectively. Fire safety and water temperature checks were up to date ensuring ongoing safety. There are sufficient toilet and washing facilities, clearly identifiable and suitably situated. The building plans for the extension had been amended to include provision of a sluice facility as previously recommended. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The recruitment and selection processes in place ensure the appointment of applicants who are suitable to work in a care home setting. The induction and foundation training programmes provide new staff members with the means to be trained to an appropriate level of competence in order to fulfil their care responsibilities. EVIDENCE: Examination of the files of two new staff showed that full Criminal Records Bureau checks had been undertaken before the offer of a position was confirmed to ensure the suitability of the applicant to work in a care home setting. Staff files were seen to hold all relevant information including references and identity checks. As the application form had requested applicants to respond to specific questions about disability and criminal activity it was recommended that reference be made to equal opportunities and disability discrimination guidelines to ensure the employment application form conforms to professional guidance in these areas. Induction and foundation training that meets National Training Organisation specifications had been accessed as previously recommended and will be introduced as new members of staff commence. Training records showed a firm commitment to providing mandatory and specialist training. Staff members had undertaken a range of training in their own time. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 17 To ensure ongoing commitment and motivation of staff to the training opportunities available a minimum of three paid training days a year is recommended. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 37 There is a culture of openness within the home and formal quality assurance systems that enable and encourage feedback as to how well the service is doing in meeting the needs of its service users. Records are maintained securely and safely in accordance with data protection requirements. EVIDENCE: There are two formal quality assurance systems in place at Clough House. These are ISO and Investors in People. Results of service user satisfaction questionnaires were displayed on the notice board and records of quality inspection outcomes were provided as evidence of the assessment activities that had been undertaken. Policies and procedures were kept under review as noted from a scheduled review sheet that identified the specific policy, the reviewing officer and the due date. Service users confirmed that they are frequently consulted about services. One service user said “staff are very helpful, always asking how we are and what we would like to do.” Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 19 The records examined during this inspection including medication, care planning and maintenance were maintained and stored in keeping with data protection requirements. A previous recommendation that personal health information be recorded in individual files had been addressed. A service user when asked said he would “not be worried about asking to see any information held” as he was quite confident there would be no problem if he wished to access his records. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x 2 x x 2 x x STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x 3 x x x 3 x Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? 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 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. Refer to Standard OP7 Good Practice Recommendations The registered manager should ensure that service users or their representatives sign the care plan review, to confirm their involvement and agreement to decisions made or provide an explanantion if a signature is not possible. The registered manager should review the medication policy and additional medication procedures against current professional guidelines to ensure they continue to conform. The registered provider should provide a sluicing facility. The registered provider should ensure that all service users private rooms are fitted with lsuitable locks and that they are provided with their own key subject to the outcome of a risk assessment. The registered manager should ensure that the application for employment form conforms to equal opportunties and disability discrimination legislation. The registered provider should ensure that staff receive at least three paid training days a year. The registered manager should ensure that reference in F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 22 2. OP9 3. 4. OP21 OP24 5. 6. 7. OP29 OP30 OP33 Clough House policies and procedures to the National Care Standards Commission should be amended to read Commission for Social Care Inspection. Clough House F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road, Chorley Lancashire, 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 F57 F08 S5915 Clough House V247580 310805 Stage 4.doc Version 1.40 Page 24 - 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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