Inspection on 08/10/07 for Cloughside

This inspection was carried out on 8th October 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cloughside 20/09/06

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 Cheryl Stovin Key Unannounced Inspection 8 and 19th October 2007 12:00 th Cloughside DS0000001048.V339156.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.V339156.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.V339156.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 www.st-annes.org.uk St Anne`s Community Services Mr Ewan Haswell Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 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 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.V339156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered during a key inspection of Cloughside. This included an unannounced visit I made to the home on 8th October 2007. A further visit was made to the home on 18th October to have discussions with the manager who was unavailable on the first visit. The purpose of the inspection was to make sure that the people living at the home are receiving the care and support they want and that they and their families are satisfied with the service. During this visit a full tour of the building was undertaken, records were examined and I spoke to management, staff and the people living at the home. In addition to this visit comment cards were sent out to give people an opportunity to share their views of the service with CSCI. Two care managers returned their comment cards and I spoke to two relatives of people living at the home. Two members of staff also returned comment cards. The information received from the surveys is included in this report. The last inspection of Cloughside was on 20th September 2006 no additional visits have been made. An Annual Quality Assurance Assessment (AQAA) completed by the home was returned promptly and gave useful information. I would like to thank everybody for their warm welcome and assistance given during this inspection. What the service does well: All of the people living at Cloughside have detailed and individual support plans which makes sure that they receive personal and health care support in line with their wishes. The staff team are well trained and were seen to be providing assistance to people in a manner which promotes independence and dignity. People living at the home appeared comfortable with the staff and relationships between them were seen to be relaxed and friendly. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 6 The home is well managed and the manager is committed to ensuring that people living at the home and the staff contribute to the decision making processes. People living at the home are protected by the recruitment procedures in the home which ensures that all the necessary checks are carried out before staff are employed. This makes sure that only suitable staff are employed at the home. People living at the home live active and varied lives and are given the opportunity to take part in social activities that they enjoy. People are supported and encouraged to maintain contact with their family and friends. One relative said the staff team were “part of the family”. What has improved since the last inspection? What they could do better: There is a programme of National Vocational Qualification (NVQ) in care in the home. Work needs to continue to meet the standard of 50 of the care staff being qualified. This makes sure that the staff team are qualified and competent to meet the needs of the people living at the home. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 7 The Commission for Social Care Inspection must be notified when physical restraint is necessary for anybody living at the home. This is to make sure that physical restraint is monitored to make sure that people living at the home and the staff are kept safe. Fire extinguishers have been removed from wall mountings for safety reasons. Advice must be taken from the fire service for alternative housings. The existing redundant wall brackets must be removed for safety reasons. 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. Cloughside DS0000001048.V339156.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.V339156.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are assessed before moving into the home to make sure that the home can meet their needs. EVIDENCE: People living at the home have their needs assessed continually and their care plan adjusted to reflect their changing needs. One person, who has mobility problems, is shortly moving to alternative accommodation in the town centre of Todmorden. The location of Cloughside isn’t really suitable for wheelchair users. The new accommodation he is moving to is right in the centre of the town which will allow him to be able to get out and about more often. His family have been fully involved in the preparations for the move and his mother said that Cloughside staff have been “very helpful and kind” during this process. The staff team are able to demonstrate that they have the skills and experience to deliver the care to the people living at the home in a caring and professional manner, and to communicate effectively. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 10 Each person has a licence agreement which gives details of the terms and conditions at the home. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s current needs are recorded in their plan of care to make sure that support is given in accordance with their needs and preferences. EVIDENCE: The care records of four of the people living at the home were seen. Each person has an individual personal support plan, which is detailed and covers activities of daily living as well as social and emotional needs. All people are routinely assessed and have detailed manual handling plans and risk assessments. The home uses a person centred planning approach and the personal support plans are reviewed on a regular basis. A daily record is kept which clearly details how people have spent their day. An ‘all about me’ document is completed for all people living at the home. This contains detailed and valuable information about the person as a ‘whole’. It gives information about their family, where they have lived in the past, any Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 12 significant events and their hobbies and interests. This makes sure that staff have as much information as possible about people living in the home and things that are important to them. Staff have a good knowledge of the communication needs of people living at the home. They are skilled in using the person’s preferred communication method. One person living at the home was having his annual Personal Planning Profile review meeting during our visit to the home. With his permission I sat in on the meeting. It was a very positive experience for all concerned. The person wasn’t feeling very well and this was taken into account during the meeting. The speech and language used was appropriate to meet his communication needs and he was fully involved in planning his goals and aspirations for the coming twelve months. Detailed risk assessments are in place which are reviewed on a regular basis, this makes sure that risks are minimised and people are kept safe. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People enjoy active and varied lifestyles and participate in a wide range of community activities whilst living at the home. EVIDENCE: All of the people living at the home take part in activities in the community. These include visits to parks, college, visits to relatives or sometimes just going for a drive. Detailed risk assessments are in place for community activities to make sure that everybody is kept safe and that risks are minimised. Staff support people to keep in touch with their family and friends and dates of their birthdays and other special occasions are recorded and the event marked. One person living at the home is of Polish origin. A Polish speaking member of staff from another St. Anne’s home visits him regularly. Together they have re-established contact with his family in Poland and they now keep in touch. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 14 Relatives I spoke to said that they are always made to feel welcome when they visit the home and that they are kept informed of important issues affecting their family member. One relative told me that visiting Cloughside is like “going home”. She also praised the staff for helping her to keep in touch with her son when she had been suffering from a period of ill health. She described how the staff had been “so kind” and had taken her son to visit her whilst she was unable to travel to visit Cloughside. Everybody living at the home has a different daily routine and staff make sure that people’s preferences are respected. People were seen to be exercising choice in where and with whom to spend their time. There are restrictions to certain areas of the home, for example, the kitchen. This is to protect the safety of the individuals and the staff working at the home. There is one person living at the home who exhibits extremely challenging behaviour. This person occasionally is ‘secluded’ in their room. Seclusion is only used in accordance with Department of Health guidelines, and in circumstances agreed by a multi-disciplinary agreement. There is a ‘spy hole’ in his bedroom door. This is justified for the health and safety of the person himself and for the safety of the staff. The decision to use any ‘seclusion’ techniques is the responsibility of the nurse in charge. The Commission for Social Care Inspection is not always informed of the use of ‘seclusion’ techniques and must be notified under Regulation 37. People living at the home receive a healthy and varied diet with likes and dislikes recorded. One person living at the home has specific dietary requirements details of which are recorded in his care plan. The meal being served was tuna pasta bake which appeared appetising and well presented. People living at the home assist with the day to day shopping for food, but do not participate in the preparation of the meals for safety reasons. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s health care needs are met and personal care is given in accordance with their preferences. People are protected by the medication practices in the home. EVIDENCE: People’s personal support needs are assessed and form part of their plan of care. People’s physical and psychological health care needs are assessed and detailed in their individual support plans. An ‘OK’ health check is completed for everybody, this is a recognised tool to help ensure the health of adults with a learning disability. All personal care is given in private, and people were seen to be treated with dignity at all times. People have all the specialist adaptations and equipment they require to make sure they are safe and comfortable at all times. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 16 One person living at the home has very complex health care needs and requires dialysis several times a day. A treatment room has been set up to make sure that the dialysis is managed in a comfortable and relaxed atmosphere. Unfortunately the person has recently broken his leg and is unable to access the treatment room as it is upstairs. The staff have worked around this very well and he and his dialysis equipment have been temporarily moved into a downstairs bedroom. Some of the people living at the home exhibit challenging behaviour and the staff are constantly looking at ways to minimise the challenging behaviours by looking for potential triggers. One person, for example, becomes anxious at shift changes. The staff have devised a board in his room which lets him know who is coming on duty and when. This has greatly diffused the situation. All of the staff are shortly to receive Positive Behaviour Support training. One of the staff at the home has been involved in devising the course and was very enthusiastic about the training to be delivered. Care Managers who returned a survey said in response to the question ‘What does the service do well?’: “Meets the needs of people who challenge, and also the high health care needs of one particular resident – to an excellent standard”. “They manage challenging behaviours well, providing consistency and structure”. The home uses a Monitored Dose System (MDS) supplied by a local pharmacy for the administration of medication Medication held at the home is securely and appropriately stored. Medication policies and procedures are in place and medication is only given to people by the qualified nursing staff in accordance with Nursing and Midwifery Council (NMC) guidelines. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are protected by the procedures and practices in the home, the staff understand and promote Adult Protection Procedures. This makes sure that people living at the home are safe. EVIDENCE: The home has a complaints procedure which is included in the service user guide and provides information of the procedure to follow and the correct contact details. The establishment holds a ‘whistle blowing’ procedure which is displayed in the staff room. The procedure details the responsibilities and obligations of the staff to report any instances of bad practices observed or suspected. All of the staff team have received training in Protection of Vulnerable Adults (POVA) and all staff spoken to are aware of the procedures to follow if they suspect that people are not being treated properly. Any incidents of physical abuse between people living at the home are reported to the local authority adult protection co-ordinator who is satisfied that the incidents are being managed in line with adult protection procedures. Cloughside DS0000001048.V339156.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean and safe environment which is furnished and fitted to an acceptable standard. EVIDENCE: The home is situated in a residential area of Walsden. The town centre of Todmorden is approximately two miles away. The shops, pubs and local facilities of Walsden are a short walk away. The home is generally well maintained, although the challenging behaviours of some of the people living there mean that the décor is damaged on a regular basis. A routine programme of maintenance is in place to help maintain the property. Since the last inspection some areas of the home have been redecorated and a new front door and windows installed. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 19 All of the people living at the home have their own spacious bedroom. Some of the bedrooms are personalised with people’s own belongings and family photographs. Some of the bedrooms are totally bare with furniture secured to the walls and floor, this is to make sure that people are kept safe if they become physically agitated. People who are able to manage are given keys to their bedrooms to make sure that their belongings are kept securely. On the first floor landing area fire extinguishers have been removed for safety reasons. The brackets that fixed them in place, however, have not been removed. These could be a potential hazard and must be removed. Advice must be sought from the fire service for an alternative housing for the fire extinguishers. There is safe and accessible garden and grounds for people to use in the warmer weather. The well equipped laundry facilities are situated in the cellar and the equipment complies with the relevant regulations. All areas of the home were seen to be clean and hygienic. Cloughside DS0000001048.V339156.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are met by a well trained and competent staff team, and are protected by the rigorous recruitment practices. EVIDENCE: There are sufficient staff employed to meet the needs of the people living at the home. There is always a Registered Nurse (Learning Disability) on duty supported by a team of a minimum of three care staff during day time hours and one waking night staff plus a member of staff ‘sleeping in’ during the night. One person living at the home has recently been in hospital and had a member of staff from the home with him at all times to make sure that his routine was not disrupted. Staff who returned a comment card felt that there are always enough staff to meet the individual needs of all the people who use the service. One person made the following additional comment: “The house is always well staffed and we work well as a team”. “I feel our service is a very good service and caters for a very broad spectrum. The staff Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 21 team in our house work very well together and management are very supportive and approachable. I feel the people who use the service are happy and feel secure and feel they are treated as individuals”. The staff team work flexibly to meet the social, recreational and special needs of people. The staff appeared to work together as a team and relationships between everybody were seen to be relaxed and friendly. Low rates of sickness and staff turnover support this. Staff told me that they support each other and that staff morale was high. One relative told me that the staff were “second to none” and that she had always had a good relationship with them. There is a commitment to training within the organisation and all new staff receive induction training to Skills for Care Council specification. There is a wide variety of other training courses which the staff attend. Staff said that they enjoy and appreciate the training opportunities provided. Staff said in their surveys that they are given training which is relevant to their role and keeps them up to date with new ways of working. One person made the following additional comment: “Initially I was given very intensive training. This is followed up with regular refresher courses as the nature of the job requires new updates, with new ideas and new ways of working”. There is a programme of National Vocational Qualification (NVQ) training in place. There have been problems with accessing assessors and under 50 of the care staff hold the award. The manager is aware that 50 of the care staff must be qualified to NVQ level 2. This makes sure that people living at the home are cared for by suitably trained and qualified staff. The staff spoken to during the inspection displayed a thorough understanding of the needs of the people. They appeared motivated and committed to providing a high standard of care and attention, and were observed to be meeting their needs in a sensitive and dignified manner. All of the people living at the home are protected by the home’s robust recruitment procedure. All staff are subject to the necessary Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA checks. An application form is completed and two written references are taken up prior to an offer of employment being made. This makes sure that only suitable staff are employed in the home. One of the people living at the home is involved in the recruitment procedure. All staff receive job descriptions and statements of terms and conditions. Cloughside DS0000001048.V339156.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42,43 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a well run and managed service. People’s health and welfare are protected by the home’s health and safety practices. EVIDENCE: The Registered Manager of the home is experienced and competent to run the home. He is a Registered Nurse (Learning Disability) and holds the National Vocational Qualification level 4 Registered Managers Award. He is committed to ensuring an open and positive atmosphere is prevalent within the home, and demonstrates a clear sense of leadership. Staff told us that he is approachable and welcomes suggestions and ideas as to how to run the home and manage situations. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 23 Management and staff work in accordance with the General Social Care Council codes of practice and other legal requirements. Financial procedures are in place to make sure that people’s money is handled safely. There is a commitment to health and safety and safe working practices in the home. All staff receive mandatory health and safety training with regular updates. Fire drills are now carried out on a regular basis and all staff receive fire safety training. Detailed risk assessments are in place which are reviewed and updated on a regular basis. Certificates were seen which showed compliance with gas and electrical regulations. As previously mentioned in the environment section of this report fire extinguishers have been removed from their brackets for health and safety reasons. Advice must be sought from the fire service about alternative housings and the redundant brackets removed. Cloughside DS0000001048.V339156.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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 3 32 2 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 3 3 x 3 3 3 x 3 2 x Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 16 Requirement To make sure that fire precautions are safe advice must be sought from the fire service regarding fixing of fire extinguishers to the wall. To make sure that people living at the home are kept safe the brackets which previously housed the fire extinguishers must be removed. To make sure that the use of physical restraint is monitored the CSCI must be notified when ‘seclusion’ of a person has taken place. The notification must give the circumstances leading to the use of physical restraint, and the length of time that the person is secluded. Timescale for action 30/11/07 2 YA42 16 30/11/07 3 YA16 37 20/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 26 1 YA32 To make sure that staff are qualified and competent 50 of the care staff must be qualified to NVQ level 2 in care. Cloughside DS0000001048.V339156.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Cloughside DS0000001048.V339156.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!