Inspection on 20/09/06 for Cloughside

This inspection was carried out on 20th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cloughside 08/10/07

Cloughside 17/02/06

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 Paula McCloy Unannounced Inspection 20th September 2006 09:30 Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 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.V304301.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 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.V304301.R01.S.doc Version 5.2 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.V304301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 2006 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 shower and toilet, a ground floor bathroom/toilet, and separate toilet, 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. The current weekly charges are £409.84. Service users pay for their own toiletries and most contribute their mobility allowance towards the running homes two cars. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection of the home took place on 17 February 2006. There have been no further visits to the home until this key inspection. This inspection was carried out to assess the home against the a predetermined selection of the National Minimum Standards for Younger Adults and to check what progress had been made on meeting the requirements from the previous inspection visit. One inspector carried out the inspection over 2 days and spent approximately 11 hours in the home. The methods used in this inspection included discussions with 2 service users, although these were limited because of service users complex needs, 1 relative, 5 members of staff, the manager, observation of care practice, examination of records, and a partial tour of the home. A pre-inspection questionnaire was sent to the home prior to this inspection visit asking for information. This questionnaire was returned to the Commission for Social Care Inspection and the information provided has been used in this report. Comment cards were sent to residents, relatives, social workers and GPs; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. One service user, three relatives one social worker and one GP wrote to the inspector with their comments. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff need to make sure that they make any necessary appointments for service users with health care professionals that are identified through the reviewing process. This will make sure that service users’ health care needs are met. The medication system at the home needs to be managed properly to make sure that service users do not run out of medication. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 7 Staff need to make sure that service users and relatives know how to complain if they need to. This will make sure that people know who to talk to if they are unhappy about anything at the home. Staff need to make sure that they use the local adult protection procedures to report incidents of abuse between service users. This will make sure that there is no complacency about levels of dangerous behaviour and that service users are kept safe. Some parts of the home are in need of redecoration in order to bring them up to standard. 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.V304301.R01.S.doc Version 5.2 Page 8 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.V304301.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users’ needs are thoroughly assessed before they move into the home. This ensures that staff can meet their care and support needs. EVIDENCE: Most of the men at Cloughside have lived there since the home opened in 1993. The last service user to move into the home did so in March 2005. Their admission to the home was looked at as part of the inspection that took place in February 2006. At this inspection the home’s admission procedures were found to be good, with all of the necessary assessment information being completed to make sure that the home could meet this person’s needs. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Detailed care plans are in place, these inform staff how individual service users’ needs are to be met. Service users are supported to make choices about their life. EVIDENCE: Two service users’ individual care plans were examined. 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 and from various members of 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 that the plans are reviewed regularly and that wherever possible family members are involved in reviews. There are some service users at the home who do not have anyone to act on their behalf. This was discussed with the registered manager. There is a meeting to be held soon with an advocacy Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 11 service and it is hoped that advocates will become involved with some of the service users at Cloughside. Some good information has 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. Valuable information was also recorded about what certain behaviours were believed to indicate and about useful methods of communicating with service users. For example one service user has no verbal communication but records tell staff that he will lead them to what he wants. Risk assessments are detailed and these are regularly reviewed. These 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. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users go out regularly with staff support and have access to all of the community facilities. Good support is provided to enable service users to keep in touch with family and friends. EVIDENCE: Staff said that each week they have a number of hours that are specifically designated for supporting service users to take part in activities. Currently service users are being supported in a range of activities e.g. College courses, trips to the library, pub, visiting friends and relatives, cookery club, walking etc. The home has its own transport or staff will support service users to use public transport if appropriate. Each service user has a leisure timetable. This shows what activities are planned for them each week. The timetable does not have to be rigidly adhered to if people are unable to go out or want to do something different. The timetabling of activities offers some individuals a much needed structure to their day, they know in advance where they will be going and what they will Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 13 be doing on a given day. It also enables arrangements to be made to ensure the home is adequately staffed to meet the needs of service users. When service users’ individual plans are reviewed new objectives are set. For one service user going out to new places was one of the objectives. The recording about how this objective was being met was not good and there was little information about what new places this service user had visited and whether or not they had enjoyed the visit. The registered manager carries out his own audit of the individual plans and has picked recording against the set objectives as a problem, and he is addressing this with individual members of staff. Staff support service users to visit friends and relatives. Also relatives said that they always feel welcome when they visit the home. One of the men living at the home is Polish and staff help him to keep in touch with his relatives in Poland. Staff said that he had also gone to some Polish clubs and said that there had been some reaction when people spoke to him in his native tongue. Staff have not pursued this but have thought they might try to recruit a volunteer who speaks Polish. This idea should be pursued. Service users’ daily routines are all different and staff know people well. Service users can choose where they sit in the home or use their own bedroom if they want to. Service users can also use the garden as and when they want to. Two service users have keys to their bedroom doors. There are some bedroom doors that have ‘spy holes’ in them, which compromise people’s privacy. These are only on the bedroom doors occupied by service users who may be secluded in their rooms. Since the last inspection one ‘spy hole’ has been removed and staff continue to keep the use of these ‘spy holes’ under review. The menus are written weekly with service users having some input regarding meals that they would like. Staff do the weekly shopping but service users are involved on a daily basis in getting milk, bread etc. In one service user’s file Polish recipes had been filed. The registered manager said staff had tried some of these but that they were expensive to prepare and they weren’t sure if the service user particularly enjoyed the different food. One service user has losing weight as an objective in their individual plan. According to the records this service user hasn’t been weighed since March 05 and there was no indication from staff that this was a current issue. If a service user has specific dietary needs these should be in their individual plan together with details of how staff are to meet this specific need. If a service user is on a reducing diet they should be weighed regularly. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 14 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 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although staff are reviewing service users’ health care needs on an annual basis, they are not making sure that the necessary appointments with health care providers identified are being made. This means that service users’ health care needs although being identified, are not being met. The medication system is not well managed, this leaves service users at risk of not getting their prescribed tablets. EVIDENCE: There was evidence on service users’ files about how they like to be supported with their personal care. Staff are in the process of completing a new document for each service user that gives more information about each individual’s preferences and the way they like to be supported by staff. The individual care plans for two service users were examined in detail. Both plans had ‘OK health check’ documents on their file. These documents are completed by staff every year and provide the opportunity for each individual’s health care needs to be reviewed. The outcome of one service user’s health care check, completed in January 2006, was that he needed an eye test, a hearing test and an appointment at the ‘well man clinic’. There was no Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 15 evidence that any of these appointments had been made. On another health check form staff had written that the date of the service user’s last eye test was not known. In the same file there were details of this person’s last eye test that had taken place in March 2004. This health care check had been completed in September 2006, but no action plan had been made e.g about what appointments were needed. Staff filling in the ‘OK health checks’ must understand the reasons for completing them and that they find out any missing information. Any necessary appointments that are identified as part of these reviews must be made. This will ensure that service users’ health care needs are identified and met. Staff at the home are continuing to support a service user who has very complex needs and requires regular dialysis. They have set up a room at the home so that this treatment can be delivered in a relaxed setting. The medication system at the home is not well managed. Although staff book in all of the medication that is received in the home and keep a running balance of medication held, the records are not accurate. For example one service user’s medication record showed that he had run out of one of his tablets, however, the nurse on duty said that this person had received the medication that morning. For another service user the medication record showed that he had 19 tablets in stock. When the stock was checked there were only 16 tablets in the packet. Without effective stock control it is not possible to clearly establish if service users have received their tablets. The possibility of using a ‘monitored dose’ system for the management of medication was discussed. The manager agreed to look as this as it would offer a solution to the problems identified. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 16 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): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff at the home need to make sure that service users and relatives know how to make a complaint, should the need arise. Staff need to make sure that they use the adult protection procedures. This will make sure that service users are safe and protected from any abuse. EVIDENCE: The home has a written complaints procedure. From the surveys one service user and one relative said they knew about the procedure. One relative, however, said they were not aware of the complaints procedure. The manager has a log in place so that any complaints that are received can be written down together with the action taken to resolve the complaint and the final outcome. No complaints have been recorded. From talking to staff when any concern is made staff tend to deal with it directly and may not automatically see it as a complaint. It is helpful if concerns/complaints are logged so that any recurrent themes can be analysed and also to show that any concerns raised are taken seriously and sorted out to people’s satisfaction. The staff at the home are notifying the Commission for Social Care Inspection about any incidents in the home that adversely affects the well being of any service user. There have been eight reported incidents of service users being hit by another service user. Staff have not been reporting these incidents to the adult protection co-ordinator who works for Calderdale Social Services, in line with the local adult protection procedures. The importance of reporting these incidents was discussed. Reporting incidents in line with the procedures Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 17 will ensure transparency and make sure there is no complacency about levels of dangerous behaviour. This will ensure that service users remain protected and safe in their home. The issue of secluding service users has featured in previous inspection reports. Seclusion has not been used at the home since July 2005. The registered manager is aware that seclusion must only be used in emergency situations as described in the Department of Health guidance. A draft policy in relation to seclusion was sent to Commission for Social Care Inspection for comment. St Anne’s are still awaiting a response to this. This issue has been passed to the provider relationship manager to look into. The registered manager holds money for safekeeping on behalf of service users. The records for two service users were examined. These were found to be accurate with receipts available for purchases made. From talking to staff it was clear that staff are careful with service users’ money. For example one service user used to go horse-riding, however, he would sometimes go and not even get on the horse. Riding was expensive and staff felt he was wasting his money and not benefiting from this activity. Staff are now looking at different activities with this service user Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 18 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, 26, 27, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and comfortable but is in need of some general redecoration and refurbishment to bring it up to standard. EVIDENCE: The home is located in a residential area of Walsden. The house has its own garden and outside seating area. There are car parking facilities to the side of the building. Staff said that approximately 5 years ago there was a possibility of the home being funded in a different way to provide supported living, however, this had not happened. Since that time there have been some cosmetic ‘patch ups’ in the home but no major redecoration. The home is now in need of redecoration. Wallpaper has been peeled off and areas of the home are generally suffering from heavy wear and tear and look generally ‘scruffy’. The front door needs replacing. Staff said that there are plans to replace the front door and adjacent glazing with UPVC units, but didn’t know when this work would be completed. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 19 The lounge is comfortably furnished, although two of the fabric chairs were rather stained and unsightly. Staff said that the leather furniture was more durable and had stood the test of time. The dining room was functional staff are encouraging service users to eat together and using large tables. The smaller tables were stacked in the corner, waiting to be disposed of. One service user spends a lot of time in the dining room listening to music. Although staff have given him a different dining chair, perhaps a more comfortable chair could be provided. Three service user bedrooms were seen. One had been made very personal with lots of art work and personal possessions. The other two rooms were not as personal but staff said this suited the needs of the service users who occupied them. There was no hot water in two of the bedrooms. The reason for this needs to be investigated and repairs made as necessary. The shower room on the first floor is operational but has not been finished. The plywood that has been used to box in the pipe work has not been painted and there is bare plasterwork on the cupboard that needs painting. The hot water to the wash hand basin in this room was only a ‘trickle’, this needs to be sorted out so that service users are able to wash their hands. The bathroom on the ground floor is kept locked because of the items that are stored in this room. The manager agreed that it should be possible for service users to have access to this room if the stored items were removed and a risk assessment completed. The bathroom and toilet on the ground floor have no natural light and are rather ‘dingy’, both of these rooms would benefit from redecoration to make them more pleasant facilities to use. The home was clean and tidy. The laundry is in the cellar. It is equipped with a washing machine and tumble drier. Staff said the equipment is adequate for the home. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 20 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are enough staff on duty to meet the needs of service users. The staff team know service users very well. The organisation needs to make sure staff get access to courses to update their training and that support staff pursue NVQ training. EVIDENCE: The duty rotas were examined. During the morning there are usually two nurses on duty with four support workers. In the evening there is one or two nurses with either three or four support workers. At night there is a nurse on waking night duty with a support worker ‘sleeping in’, who is available if needed. A lot of the staff at Cloughside have worked there for a number of years. Staff said that as a rule they do not use any 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. There are currently vacancies at the home for two full time support workers. At the time of this inspection the manager had been told that he was overspent on his staffing budget. He felt that this was a mistake by head office, but was being cautious about filling posts until this problem had been resolved. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 21 The recruitment files for four staff were requested on the first day of the inspection. There was an agreement in place with St Anne’s that files would be made available in the workplace for inspection, however, human resources would not release the requested files. This issue has been taken up with the provider relationship manager that provides the link between the Commission for Social Care Inspection and St Anne’s to resolve. The provider relationship manager for the Commission for Social Care Inspection inspected a sample of staff files in April 2006. His findings were that generally recruitment practices were good, with all of the necessary checks being undertaken. There are only 7.7 of the support workers who have completed their NVQ level 2 training. All new staff that are recruited are aware that they will be expected to complete specific learning disability training (LDAF) and undertake NVQ training. There are members of staff who are NVQ assessors in the home. The manager said that they need to update their own training before they can take staff through their NVQ awards. All staff undertake mandatory training in food hygiene, health and safety, adult protection, emergency first aid and moving and handling. Some staff said that they are due to update some of their training, but they are having difficulty accessing courses at the moment. The registered manager explained that there is no training manager in place for the organisation and the training programme isn’t running as it should be. This situation needs to be resolved so that staff receive the updates they need to make sure their practice is up to date. The registered manager is currently undertaking training, which when completed will be cascaded to all of the other staff in the home. This training is about staff trying to look at what might cause service users’ particular behaviours and then trying to put specific strategies in place to prevent them happening. (Positive range of options to avoid crisis and use therapy strategies for crisis intervention and prevention.) The manager hopes to provide this training to all staff by May 2007. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 22 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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed and is run in the best interests of service users. EVIDENCE: The registered manager of the home is a learning disabilities nurse who has completed the registered managers award. St Anne’s have a quality assurance system in place, and recently questionnaires have been sent out. The registered manager thought that this process was set up to look at the service St Anne’s provide as a whole, rather than just the service at Cloughside. It would be helpful if the home had their own feedback about the specific service they provide. One of the service managers for St Anne’s undertakes monthly visits. Written reports of these visits are available at the home and copies are sent to the Commission for Social Care Inspection. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 23 The home’s management of health and safety is generally good. All staff receive mandatory training in health and safety, fire safety, emergency first aid, moving and handling and food hygiene. Risk assessments are in place for staff in relation to safe working practices. Health and safety checks are made monthly and gas and electrical wiring certificates were up to date. A fire drill was held in May 2006. Staff have recently started a new fire alarm test record book. The last recorded fire alarm test took place on 31/07/06. Staff must make sure that this test is completed on a weekly basis to check the system is working properly. Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 24 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 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 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 3 X X 3 X Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 12 Requirement Staff must make sure that the health care reviews are fully completed and that any appointments that are identified and needed with health care professionals are made. The medication system must be managed properly. Administration records must be accurately completed and balances of medication held must tally with the records. The manager must ensure that relatives have a written copy of the complaints procedure and that they know how to complain, should the need arise. Staff must use the local adult protection procedures and report any incidents of abuse. A programme of redecoration and refurbishment for the home must be available that gives timescales for the completion of the identified works. This should include; The corridors Ground floor bathroom Shower room Ground floor toilet DS0000001048.V304301.R01.S.doc Timescale for action 30/11/06 2 YA20 13 07/11/06 3 YA22 22 30/11/06 4 5 YA23 13 23 07/11/06 30/11/06 YA24 Cloughside Version 5.2 Page 26 Bedrooms Replacement of the front door 6 YA43 23 The fire alarms must be tested on a weekly basis and details of these tests recorded. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA7 YA24 Good Practice Recommendations Staff should try and involve advocates for those service users who have any relatives involved in their care and support. 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 The manager at the home should consider using a monitored dose system for the administration of medication. Staff should log complaints, however minor, and use this information to continue to develop their service. The budget for the home’s staffing needs to be sorted out, so that the manager has up to date and accurate information. 3 4 5 YA20 YA22 YA33 Cloughside DS0000001048.V304301.R01.S.doc Version 5.2 Page 27 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.V304301.R01.S.doc Version 5.2 Page 28 - 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!