Inspection on 08/05/07 for Clough House

This inspection was carried out on 8th May 2007.

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

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

Other inspections for this house

Clough House 19/10/05

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 Mr Patrick Rooney Unannounced Inspection 8th May 2007 10:00 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.V340417.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. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 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 01772 436890 Clough House Residential Home Limited Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Clough House DS0000005915.V340417.R01.S.doc Version 5.2 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. 19th October 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 and is owned is 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. Fees for the home are currently £415 per week. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit and took place over a period of three hours. The information in this report was gathered from a pre inspection questionnaire completed by management of the home, discussion with the owner and discussion with staff individually. Private discussions were held with relatives and residents. The care of three residents was case tracked, their assessments and care plans were seen and the inspector interviewed them regarding the care they receive. Other residents were spoken to in the lounges. Questionnaires were received from residents and relatives. A tour of the premises took place and documents were seen by the inspector. Staff records were examined and three staff interviewed privately. What the service does well: What has improved since the last inspection? Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 6 The home is constantly being improved and decorated and plans are being made to carry out an extension. Suitable locks have been put on resident’s bedroom doors, which ensure they have the option to lock them if they wish. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 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.V340417.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Assessment and information processes for obtaining a place at the home ensure residents are informed as much as possible about obtaining a place at the home. 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 are regularly reviewed and are up to date. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 9 All residents are admitted after a full assessment is carried out, with their and or their representative’s full involvement. One area requiring some attention is that there was little information contained in assessments of social and cultural background information. This was the case with three care files looked at during the visit. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good care plans, which reflect the needs of residents and ensure that staff are able to ensure the privacy, dignity and independence of residents. Medication procedures are thorough and underpinned by professional guidance to promote good practice. EVIDENCE: The service user plan of care detailed all aspects of health and personal care needs of the individual. Three care plans seen confirmed this to be the case, however there was little information recorded regarding social background and interests. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 11 Care plans are readily accessible to staff and had been updated daily. In most cases care plan reviews had been signed by the resident concerned or their representative to confirm their agreement to the review outcome. In speaking to residents about their care it was noted that are satisfied with the care they receive and the sensitive caring way it is provided. Comments from residents included, “the staff look after me very well, I am very happy here”. “The staff are really kind and helpful, they make sure I get everything I need” Relatives comments include “ they care for people extremely well and always seek immediate medical attention if anyone is unwell. The staff are very caring, as a relative I am always made welcome and kept fully informed”. “ I cannot think of any improvement, I am quite satisfied with the care she gets, if she needs a doctor they send for one and keep me informed”. The medication policies and procedures were looked at, these ensure medication is received, stored and administered safely. Records seen were up to date and in order. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines are flexible and take into consideration the individual needs and wishes of residents. EVIDENCE: The inspector saw a varied programme of activities for residents, which includes entertainment sessions, books, quizzes, outings, and visiting shops. The atmosphere in the home was observed to be relaxed, residents told the inspector they are able to rise and retire when they wish and that mealtimes are flexible according to their needs and wishes. Meals may be taken privately if residents wish. Residents told the inspector that staff are very kind and caring and relatives said that the home is relaxed and has a very pleasant atmosphere. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 13 Resident told the inspector that food they receive is excellent and there are always alternatives provided. Individual likes and dislikes are recorded and menus are discussed with residents. Residents said, the food is excellent. The inspector looked at menus and spoke to the cook, there is always a good variety of fresh food available and all meals are home cooked. Residents are asked about what food they like and are able to ensure this is included in menus. 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. 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. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure, relatives and residents are confident that their concerns are listened to, taken seriously and acted upon. The homes vulnerable adults procedure ensures people living at the home are protected from abuse. EVIDENCE: There is a complaints procedure available to residents and there families, this is available in the service users guide and is on the homes notice board. Residents confirmed they are aware of the complaints procedure and told the inspector that any concerns they have are dealt with promptly. The homes owners are always available in the home; residents said they are very approachable and helpful. Residents said they have confidence in the owners and feel able to raise anything that is of concern. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 15 The inspector saw the homes vulnerable adults procedures including the whistle blowing policy. These are in line with the Department Of Health, ‘No Secrets’ paper. Staff on duty were spoken to individually and said were aware of the whistle blowing policy and said felt confident to approach the owners if they had any concerns. Training records showed that at present only one member of staff has received training in protection of vulnerable adults. More staff should receive this training. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a good standard of décor and furnishings, which provide residents with a homely clean and comfortable environment. EVIDENCE: The inspector toured the home and viewed the rooms of residents, he observed them to be comfortably furnished and contained items residents were able to bring with them when they were admitted to the home. Public areas of the home were seen to be comfortably furnished and decorated. All residents spoken to say they were happy with accommodation provided by the home. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 17 There is an on going programme in place for refurbishment and decoration. There are good infection control procedures in place and the home is always kept clean, this was observed to be the case at the time of the visit. 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 sluice facility. Locks with a suitable override facility are 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. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the right numbers of staff on rota, with training and experience to meet the needs of residents. The procedures for the recruitment of staff are robust and offer protection to people living in the home. EVIDENCE: The inspector spoke to management and interviewed three staff. Rotas and staff records were examined. It was noted that there is a stable staff group who have the experience and skills to provide care needed for residents living in the home. All staff have received a staff induction, which ensure they are familiar with the homes policies and procedures and the basic principles of care. Records show that above 66 of the staff employed in the home are qualified to NVQ 2 or above in care. Three more staff are due to do this training and one is doing NVQ3. Staff supervision and appraisal records ensure staff training needs are identified and appropriate training provided. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 19 Questionnaires received from residents and relatives confirmed that staff provide the right level of support to residents. Rotas showed that there are sufficient numbers of staff on duty to meet the needs of residents. Residents said that staff are very friendly and approachable, and said all staff are very good and helpful. The files of staff were viewed and showed that all necessary recruitment checks are made including Criminal Records Bureau checks. References are taken up and interviews held prior to a post being offered. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, which ensures residents interests are protected and health and safety issues are promoted. EVIDENCE: While there is currently no registered manager in post, one of the owners is currently managing the home; she is experienced and has been involved in running care homes for many years. It is envisaged that a registered manager will be appointed in the near future. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 21 Both the owners are in the home every day and are well known to residents. Residents told the inspector they are able to approach the owners with any concerns they may have and that these are quickly acted on. Residents and staff are happy with how the home is run and there are clear lines of accountability. Resident’s views are taken seriously and resident surveys have been carried out. Both residents and staff feel they are able to approach the owners with any ideas or issues they may have. Brookside is accredited with ISO 900 and Investors In People has annual assessments to keep these in place. Most residents or their families/representatives, hold full responsibility for their own finances. In the instance where limited support was provided, a written record of transactions has been maintained. Secure facilities are available should any resident require money or valuables to be held for safekeeping. All the homes policies and procedures are reviewed and updated. Health and safety is taken seriously and staff receive training in moving and handling, health and safety and first aid. All safety certificates and risk assessments are carried out and are up to date. There is a system in place for staff supervision and annual appraisal, however at the time of the visit this needed updating to ensure that staff receive regular one to one supervision. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 23 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. Refer to Standard OP3 OP18 OP36 Good Practice Recommendations Assessments and care plans should contain better details regarding social background, hobbies and interests. All staff should receive training in protection of vulnerable adults Staff should receive regular one to one supervision. Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Clough House DS0000005915.V340417.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!