Inspection on 17/02/06 for Cloughside

This inspection was carried out on 17th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cloughside 08/10/07

Cloughside 20/09/06

Cloughside 27/09/05

Cloughside 11/03/05

Cloughside 14/10/04

Cloughside 04/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Cloughside Cloughside House Winterbutlee Road Walsden Todmorden Lancashire OL14 7QJ Lead Inspector Lynda Jones Unannounced Inspection 17th February 2006 10:15 Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 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 Cloughside DS0000001048.V265874.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 Adults 18-65. 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. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cloughside Address 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) Cloughside House Winterbutlee Road Walsden Todmorden Lancashire OL14 7QJ 01706 819493 St Anne`s Community Services Mr Ewan Haswell Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Cloughside Care Home offers 24 hour nursing and personal care to 7 adults with learning disabilities. The home is operated by St Anne’s Shelter and Housing Action. Accommodation consists of 7 single bedrooms, an upstairs bathroom/ shower/ WC, a ground floor bathroom/ WC, and separate WC, a lounge, dining room, kitchen, staff office and basement laundry. Externally there are fenced gardens to the front and rear of the property. Local shops are within approximately 15 minutes walking distance, and there is easy access to the local towns of Todmorden and Littleborough by bus and train. The bus stop and train stations are two minutes walk from the home. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk The last inspection of the home was unannounced and took place in September 2005. There have been no further visits until this inspection. This was an unannounced inspection carried out by two inspectors over a 5.45 hour period. The main purpose of the inspection was to make sure that the home continues to provide a good standard of care for the people who live there. The methods used at this inspection included looking at care records & talking to staff about the sort of activities that service users are involved in. Discussion took place with the manager and deputy manager about the training opportunities that are available to staff. Due to their complex needs discussion between the inspectors and service users was limited. During this inspection, the bathrooms and communal areas of the house were viewed and two service users invited inspectors to see their bedrooms. What the service does well: Pre admission assessments do not take place very often as most people have lived at the home for a number of years. The most recent assessment of a prospective service user was detailed and carefully conducted to make sure the service users needs could be met at Cloughside. Personal profiles contain some valuable information about the life experiences of people living at the home. Personal plans include detailed information about how individual needs are to be met. The daily records demonstrate how the care plans are implemented. The plans are regularly reviewed. Staff have a good understanding of the daily routines preferred by each individual and they support service users to maintain this structure. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 6 All service users have good opportunities to take part in activities that they enjoy. The staffing levels at the home enable the staff to offer appropriate support. Service users are supported to maintain contact with their families. Relatives are involved in the personal planning meetings that take place. There are good systems in place to ensure that healthcare needs are carefully monitored. The opportunities for staff training are good. What has improved since the last inspection? 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. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users’ needs are thoroughly assessed before they move into the home. EVIDENCE: As most of the men at Cloughside have lived there since the home was first established in 1993, there has been only limited opportunity over the years to put the St Anne’s admissions procedure into practice. However staff were asked to assess a prospective service user in 2005. The most recent person to take up residence at Cloughside, moved there in March 2005. The records show that a detailed assessment of the needs of this service user was undertaken before he moved to the home. The assessment took into consideration the suitability of the layout of Cloughside, staffing considerations and how the specific individual needs of this individual could best be met. The records show that those involved in the assessment took time to consider the impact that any change may have on the other people already living at Cloughside. Records indicate that relatives were involved alongside a multi disciplinary team of staff who provide care and support to people with learning disabilities. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Detailed care plans are in place informing staff how to meet individuals’ assessed needs. Risk management is good. Service users are supported to make choices about their lives. EVIDENCE: Two service users’ individual care plans were examined as part of this inspection. Personal profiles contained valuable information about the life experiences of each person, where they had lived in the past, how life had been and what life was like now. Information had been collated from earlier records, from family members and from various staff who knew service users well. Personal plans were found to contain detailed information about how assessed needs should be met. Daily records are kept to indicate whether or not individual care plans have been implemented as intended. There was evidence Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 10 that the plans were reviewed regularly and that wherever possible family members were involved in reviews. Some good information had been recorded about the daily routines preferred by individuals. Detailed records indicated how staff should provide support to people to help them to maintain their routines. During the course of the visit it was noted that service users who were at home for the morning, got up and had breakfast when they wished. The morning routine was taken at a leisurely pace, after breakfast some people chose to return to their rooms. Valuable information was recorded about what certain behaviours were believed to indicate and about useful methods of communicating with service users. The records indicated that people were encouraged to use their basic self-help skills and to be as independent as possible. Risk assessments are detailed and there is evidence that these are regularly reviewed. The assessments identify risks to and from service users. Identified risks are appropriately assessed and there is clear guidance for staff about the action they need to take to minimize risks. The home provides nursing care to people with severe to profound learning disabilities who have associated challenging behaviours and seclusion is sometimes used. The records show that seclusion was last used in July 2005. The Commission for Social Care Inspection is notified by the home whenever seclusion is used, this will continue to be monitored. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,14,15,16. The staff support service users to go out regularly to take part in leisure activities. Good support is provided to enable service user to keep in touch with family and friends. Staff support service users to be as independent as possible and to make choices about their lives. EVIDENCE: Staff reported that each week they have a number of hours that are specifically designated for supporting service users to take part in leisure activities. The home has access to its own transport in the form of two people carriers, where possible service users are also supported to use public transport when they go out. Each person has a leisure timetable, which shows what activities are planned for them for the week. This does not have to be rigidly adhered to if people are unable to go out for any reason. The timetabling of activities offers some individuals a much needed structure to their day, they know in advance where Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 12 they will be going and what they will be doing on a given day. It also enables arrangements to be made to ensure that the home is adequately staffed to meet the needs of all service users. Records show that everyone has the opportunity to have a holiday or go for day trips during the course of the year. Arrangements were already underway for trips further afield when the weather improves. Staff reported that they had good links with the families of service users and that they support and encourage service users to maintain their relationships with their family and friends. Relatives are made very welcome when they call at the home and are welcome to join the trips out that are organised. In the last report reference was made to the view holes on some of the bedroom doors. These are only on the bedroom doors occupied by service users who may at times be secluded in their rooms. Discussion took place with the manager and deputy manager about this during feedback at the end of the inspection. Inspectors felt that consideration should be given to obscuring, and planning to remove the view holes from the rooms occupied by service users where seclusion had not been used for some time. The management team agreed to review these arrangements. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Staff deal with health care issues in a thoughtful and sensitive way. The systems in place for monitoring the health care needs of service users are good. EVIDENCE: There was evidence in service user records to show that healthcare needs are regularly assessed and addressed. A detailed “OK health check” had been completed in respect of each person and was reviewed annually. A health action plan generated from the health check shows for example, when appointments were due with the dentist, optician, chiropodist etc. The action plans also gives details of any concerns about health related issues and how these are being monitored. One service user has some complex health needs requiring regular dialysis. The staff have done some excellent work to ensure that this is conducted in a relaxed setting, minimizing risks as much as possible. Improvement was noted in the details recorded about the use of PRN (as required) medication. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this inspection. See last report. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30. Service users live in a clean, pleasantly furnished home. Each person has their own bedroom. A range of comfortable shared space is also available. Certain parts of the home would benefit from redecoration. EVIDENCE: The shared areas of the home were noted to be clean, warm and comfortably furnished. The house is large enough for people to have their own personal space and to be able to spend time alone if they wish. Two service users showed their rooms to inspectors. There was evidence that each person had lots of their own personal possessions around them. One person spends time in his room watching TV and listening to music, the room was organised so that he could do this in comfort. Parts of the house are in need of upgrading due to the constant wear and tear on the interior. Staff have made some good attempts to patch bits of décor on the corridors and stairways where signs have been pulled off the walls. The atmosphere at the home was reported to be much more settled of late and as a result there has been a reduction in the amount of damage around the house. This may be a good opportunity for a programme of redecoration to commence. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 16 Work was almost complete on the first floor “wet room”. The shower/toilet facilities in this room in this room will be a positive improvement for service users. It was noted that some old cloths had been placed at the bottom of the inside of the front door. Staff thought this might have been done to prevent a draught blowing under the door, making it cold in the nearby sitting area. These should be replaced with a more appropriate draught excluder, as this is a fire exit. The toilet roll holder in the ground floor toilet needs to be moved so that it can be easily reached. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 There is a stable staff team at the home, who know the service users very well. The home is adequately staffed to meet the needs of service users. Training opportunities for staff are good. EVIDENCE: The majority of staff working at Cloughside have been employed there for a number of years. Staff report that as a rule they do not need to use agency staff. Gaps on the rota are usually covered by staff working additional hours or by staff from another St Anne’s home. This helps to ensure that service users are familiar with staff and vice versa, it should also ensure that care and support are delivered with some consistency. Staff on duty said they felt that the home was adequately staffed to allow them time to offer appropriate support to service users. They said there was sufficient flexibility on the rota to allow more intensive support to be provided when people were going out on activities, to hospital/doctors appointments and on trips out. All of the staff at the home have received training in Managing Aggression and Violence and continue to receive regular updated training. All staff undertake mandatory training in food hygiene, health and safety, adult protection, emergency aid and moving and handling. The records show that Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 18 training needs are monitored through staff supervision. Regular audits of training take place to make sure that all training is regularly updated. All qualified staff have undertaken specialised training so that they can offer support with renal dialysis. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 Records are securely held and well maintained. EVIDENCE: All of the records that were examined during the course of this inspection were found to be up to date. Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X X X 3 X X Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 21 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. 7. Standard YA16 Regulation Requirement Timescale for action 30/04/06 12(3)(4)a, The registered person must 13(6) review the current arrangements in respect of the view holes that are in some of the bedroom doors. The use of these measures must be agreed and recorded. There must be a clear rationale for retaining the view holes, which must be kept under regular review so that they can be obscured or removed wherever possible. 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 Good Practice Recommendations An audit of the home needs to needs to be carried out to identify and plan to redecorate those areas where the décor has been damaged YA24 Cloughside DS0000001048.V265874.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Cloughside DS0000001048.V265874.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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