Inspection on 31/07/04 for Clover House

Care Homes For Adults (18 ­ 65)Clover House40 St Johns Road Morecambe Lancashire LA3 1EXAnnounced Inspection31st July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Clover House Address 40 St Johns Road, Morecambe, Lancashire, LA3 1EX Email address Tel No: 01524 426444 Fax No: 01524 426937Name of registered provider(s)/company (if applicable) Clover Care Group (Mrs M Bradley) Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 6Category(ies) of registration, with (number of places) Learning disability (6) Registration number F090000088 Date first registered 19th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th July 2002 yes NO 23/1/04 If Yes refer to Part CClover HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 331st July 2004 10:00 am Mrs Jennifer DunkeldID Code079353Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr & Mrs BradleyClover HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementClover HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Clover House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Clover HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Clover House is a care home offering personal care and accommodation to 6 people with a learning disability. It is owned by Mr and Mrs Bradley and managed on a day-to-day basis by Mrs Maria Bradley. The home is a 3-storey semi detached building offering each service user the type of room they currently require. 4 service users have a single type of bedroom and 2 service users share a twin room from choice. The home is situated at the West End of Morecambe relatively close to the promenade and its amenities. There are 2 lounges and a kitchen/dining room. There is a recently built conservatory at the rear of the home offering the service users further opportunity to have shared space or use on their own. The home has a rear garden and a drive way to the front and side of the home.The service users are enabled to access local community health care e.g. G.P, Dentist and, Chiropodist. The home actively promotes the integration of people with a learning disability and enabling them to achieve their goals, in an age appropriate and respectful mannerClover HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was carried on one day in July 2004 and focused on a selection of the National Minimum Standards for younger adults. All the standards that were assessed were met in full and the overall quality of care was good. The remaining of these standards will be addressed during the next inspection of this home. The service at Clover House is committed to ensuring that people with a learning disability have their right to a quality life that gives fulfilment, is met in the most appropriate ways. The findings of this inspection confirmed that the management team achieve this philosophy. Comment cards were received from a number of service users and the others were spoken with during this visit, all revealed that the service users are happy with the care they receive. CHOICE OF HOME (Standards 1-5 .) All 5 Standards were assessed of which 2 were exceeded, 2 were met and was almost met. A Statement of Purpose is available at the home and given to prospective service users, their family/ carer to enhance the decision making process as to whether to have trial stay at Clover House. In addition to this a full assessment is carried out before a placement is offered to ensure the home has the necessary facilities to meet the needs of the individual. Opportunities are provided for prospective service users to visit the home and meet the other service users and the staff team. The needs of some of the service users cannot be fully met due to inappropriate funding. The service provider is currently liaising with the funding authority in relation to this. HEALTH AND PERSONAL CARE (Standards 18-21.) 1 Standard was assessed and exceeded. Each service user has a written plan of care, a Person Centred Plan that they and people who have a significant role in their life have helped to develop. This stems from the pre admission assessment, which usually takes place in the individuals own living environment. The Person Centred Plan includes risk assessments where appropriate. There is a clear recognition of the importance of privacy and dignity for the people who reside at Clover House. DAILY LIFE AND SOCIAL ACTIVITIES. (Standards 6-17.) Ten Standards were assessed of which 6 were exceeded and 4 were met. The service users talked with the inspector about their daily life and social activities and were full of praise for how they are enabled to follow their chosen pursuits and talked about their holidays. The activities are as varied as the service users themselves, who have their uniqueness respected. However one service user was clearly upset at being told by the Day Centre that he can no longer attend the centre as he lives in residential care. Whilst this is not of the service user nor service providers choosing, the service provider needs to liaise with the Day Centre to ascertain if this could be a gradual process rather than an instant cut off COMPLAINTS (Standards 22 &23.) These standards were assessed during the previous Clover House Page 6 inspection and were fully met. A robust complaints procedure is in situ and each service user has a copy of it. The service users confirmed this. Neither the home nor the National Care Standards Commission have received any complaints since the last inspection. ENVIRONMENT (Standards 24- 30). 3 Standards were assessed and met. The home is clean, well maintained and in good decorative order. Since the last inspection a conservatory has been added to the rear of the home and this enhances the current STAFFING (Standards 31-36) 4 standards were assessed of which 3 were exceeded and 1 was met. The staffing level of the home meets the needs of the service users most of the time however the increase in funding for some service users would enable their choice of activities with appropriate staff support. The Management team at Clover House have a positive attitude about the importance of having a well-trained team of staff who have the skills and competences to meet the needs of the service users. The inspector viewed the Training and Development Matrix for the staff this covered a wealth of topics e.g. Principles of Care, Your role as a professional, Challenging Behaviour, Abuse, Fire Safety and Basic Food Hygiene to name but a few. A waking night staff is also employed with the Service Provider on call via an intercom to their house which is across the rear garden of Clover House. 70 of the staff have achieved the National Vocational Qualification level 2 or above. MANAGEMENT (Standards 37-43) 6 Standards were assessed of which 2 were met and 4 were exceeded. Clover House is effectively managed by people who are competent to do so and have achieved the Registered Managers Award. An effective quality monitoring system is in situ. Indeed the management team have undertaken training in the techniques of Internal Quality Systems Monitoring.Clover HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Clover HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 18(1)(a) YA3 The service provider must liaise with the funding authority to ensure the home has the capacity to meet the assessed needs of the ser vice users. 16/9/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The service provider should liaise with the Day Centre to ensure the move away from the Day Centre is at a pace he chooses and not one that is imposed upon him by the Centre1YA12· Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10. ·PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Clover House Page 9 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES YES YES YES NO YES YES YES NO YES YES YES NO YES YES NO YES 3 0 0 YES NA YES YES 9 0 31/7/04 10.00 3.15The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: Clover House Page 10 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Clover HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 319 670 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 4 Key findings/Evidence Standard met? As stated following a previous inspection there is a Statement of Purpose and a Service Users Guide that is written in a user-friendly manner. The requirements of this standard are incorporated into these documents. The current service users have been involved in the developing of the Service Users Guide and have a copy of this. Pictures and photographs are used to aid understanding. The service provider stated that there has been no change to these documents other that the staff qualifications have been up dated.Clover HousePage 12 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? During a previous inspection the management team explained that people are assessed prior to admission. Wherever possible this takes place in the persons own living environment. The homes pre admission procedure verified this. Clover House has an Emergency Admission Policy and an Admission Policy. Following admission, the service provider develops with the service user a Person Centred Plan. Evidence of this standard being met was by viewing the assessment plan and Person Centred Plan for the most recent service user. These were clearly written and reflected the needs of the service user. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The service provider must liaise with the funding authority to ensure the needs of the service users can be met in the most appropriate manner. Some of the service users have their needs fully met with appropriate staffing levels to meet their needs. At the time of the visit two service users had appropriate staff support to enable them to follow the activities of their choosing. However some of the service users have been in residential care a number of years and as such are now in need of a re-assessment by the funding authority to ensure peoples needs can be met. The homes assessment of these individuals would now appear to raise the need for a higher funding levelClover HousePage 13 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 4 Key findings/Evidence Standard met? The management at Clover House invite prospective service users to visit the home in order to meet the other service users and the staff. The individual is initially admitted on a trial basis. The trial basis can be extended depending upon the needs of the individual. The home has a policy which states No emergency admission will be admitted into this home This policy also states In the case of a placement made under the Mental Health Act ­ Guardianship Order, all relevant sections of the admission policies and procedures still apply. The existing service users are consulted as to the suitability of the prospective service user following the trial period, before a permanent placement is offered.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The home follows the contract of the funding authority. The Inspector viewed these. The information required of this standard is available for each service user in various documents. The home has developed their own statement of terms and conditions format, which incorporates all the information into one document for each individual.Clover HousePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? The inspector looked at two service users Person Centred Plans as part of the `case tracking process. The plans viewed reflected people needs and how these were to be met. 1 service user attends Lancaster and Morecambe college 4 days per week studying for G.C.S.Es. The service user also has appropriate support to go out and follow her chosen activities on the other 3 days of the week. Her goals and wishes were also recorded and reflected her inner most desires. This service user writes her own daily notes. The file also contained Risk Assessments as necessary. The 2nd service users plan reflected that until recently he had from choice attended a Day Centre but had been informed by the funding authority that his placement was now to cease and other activities looked into. The service user showed the inspector a farewell card that staff and friends at the Day centre had signed. He was visibly distressed at this known and enjoyed part of his life coming to an end. The service provider should liaise with the funding authority for this placement to be withdrawn gradually in order to give the service user opportunity to become familiar with other activities before this is taken from him. He has attended the day centre for a large part of his life. His leisure activities include Church and church meetings. Watching sport. Dancing, he attends a dancing club. This service user has been assessed by the home as needing staff support to follow other activities such as Line- Dancing, shopping trips etc. There is a clear determination on behalf of the service provider to ensure service users needs are met in the most appropriate way.Clover HousePage 15 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionStandard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 4 Key findings/Evidence Standard met? From observation and discussion with the service users and management it is apparent that this standard is met In relation to staff selection all staff appointments are subject to each service user agreeing the member of staff is acceptable at the end of the probation period. This was evidenced by the client opinion of new employee in the staff records file. The inspector viewed user satisfaction forms and these reflected that people were content in the care they receive at Clover House. The home also has a suggestions box in which service users can anonymously place their suggestions. However because of the good rapport between the management and the service users, the service users freely express their views about the running of the home and other aspects of care.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 4 Key findings/Evidence Standard met? The people who live in the home are enabled to take risks, in order to increase independence. This was evidenced in Person Centred Plans and risk assessments. The homes Risk Taking and Risk Management policy includes the following statement this policy is intended to set out the values, principles and policies underpinning this homes approach to individual risk management and independence of its service users. The staff spoken with were aware of the need for people to be enabled to take calculated risks.Clover HousePage 16 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? This standard is highly promoted at Clover House where there is a strong emphasis in enabling people to reach their potential. The Person centred plans are evidence of this and the discussions with the service users confirmed this standard is met. The service users stated that they are enabled to do as much for themselves as possible and to follow their chosen activities. Most of the service users require staff support to follow many of their chosen activities, this is only restricted at times due to the lack of appropriate funding to meet the changing needs of the service users. This is an issue the service provider is currently raising with the funding authority involved. The service users participate in the local and wider community. College courses are enjoyed by a number of service users who chose their individual courses. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 4 Key findings/Evidence Standard met? For a person with a learning disability it can be difficult to find employment, however if that is what the individual wishes then the Team at Clover House would do their best to enable the service user to procure employment. Indeed one man now works for the local Football Club, a job which in his own words he loves. Another service user has recently been to the local Job centre for an interview. One retired service user now accesses the local Rainbow Centre and she thoroughly enjoys this. Clover House Page 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Evidence that this standard is met, was via discussion with service users and staff, the Inspectors observation and from the individual plans. Staff time to enable activities is evidenced in the costing for care, which reflects where one to one support is necessary. This is procured for some service users, where as others are in need of a re-assessment to ensure their changing needs are appropriately met. The local facilities such as pubs and clubs are accessed. People who choose to follow their religious beliefs are enabled to do so and attend the church of their choice. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? The choice of activities at Clover House is as wide as the individuals choose.4One man who until living at Clover House had spent much of his time in his room and rarely participated in activities spoke with the inspector during a previous inspection of how he was enjoying life and spoke of his various activities and showed her photographs of a ski-ing holiday he had enjoyed. The inspector observed the encouragement that is given by the staff team to the service users. Activities are an important aspect of life at Clover House; some have to be planned for ensuring the appropriate staff support is available. One service user has recently had driving lessons. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The people who live at Clover House spoke of the ways in which they are enabled to maintain contact with their friends and family, for example they invite friends to tea. In respect of service users friends visiting there are rules of the house to ensure that visitors to one service user do not upset the other service users by their behaviour or bad language. This reflects that there is welcoming and open atmosphere.Clover HousePage 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? As previously stated there are rules of the house but these have been drawn up by the service users for their individual and collective well being/safety. The service users are all happy living at Clover house where they state there is a family atmosphere. Each service user has a key to their own bedroom and one to the front door of Clover House, which enables people to see this as their home and to independently enter the house. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The evidence that this standard is met was by the inspector observing the meal that was being served on the day of the visit and from the discussions with the service users who stated that the food was good. The record of meals served was further evidence of the well-balanced and nutritious mealsClover HousePage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 4 Key findings/Evidence Standard met? The Inspector found this standard to be met by use of the following methods; observation and discussion with service users who stated that the staff were kind. The people who live at Clover house are all very different in personality and this is reflected in their appearance. Additional specialist support is provided as necessary for example Lancashire Advocacy Service, Physiotherapist, Psychologist, Psychiatrist are some of the professionals whose support and advice is being utilised. One service user has a sign on her bedroom stating `Please knock and wait if I dont answer after 3 knocks I give the staff permission to come in and check on me. This enhances the service users privacy whilst ensuring her well being. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspection 00 0Clover HousePage 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionStandard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 0Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES0 0Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The inspector found this standard to be met in that the home is in keeping with the local community and has an ambience that reflects the homes purpose. The home offers access to local amenities. The home has a planned maintenance programme, which has been previously seen by the inspector. The service users spoken with confirmed that they were happy with their bedrooms and it was obvious that they can furnish and decorate them as they wish and they are encouraged to display personal items. The home appeared clean and well maintained and its appearance gave the feel of a comfortable, homely and friendly one. The new conservatory has added to the facilities available within the home. One bathroom has been retiled since the last inspection and has a much brighter appearance.Clover HousePage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 4 1 1 0 0 4 X0 0 1 0Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspection 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionStandard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? In addition to the two lounges there is now a conservatory The front lounge is used by service users to speak with their visitors in private without having to go to their bedroom unless they choose to do so. There is also a kitchen/dining room.Clover HousePage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? One service user due to increasing age related ailments has a need for grab rails in the toilet. This has been provided following advice from the Community Occupational Therapist. There are also Grab rails at the back door of the home and on the stairway. This standard is met in that services are provided in line with the homes stated purpose. The home also has a new call system that enables service users to summon assistance when necessary. The call bell is of a type where the alarm can only be cancelled at the source. This is a desired system.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionStandard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This Standard was assessed and fully met during the previous inspectionClover HousePage 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX4 Key findings/Evidence Standard met? The Inspector found evidence that this standard was met by viewing staff records, which included 2 references and a Criminal Records Bureau clearance. Service users are consulted after the member of staffs probation period as to whether or not he/she should be offered a permanent contract. They repeat this process at least every 12 months. The staff are aware that the service users will be commenting on their work performance and attitude. The Inspector also spoke with the service users and observed practices to verify this standard was met. Rosters confirmed that the home was adequately staffed at times but is seeking a reassessment by the funding authority to ensure peoples needs can be met in the most appropriate way. The training and Development Matrix viewed on the staff files viewed included; Moving and handling Basic Food Hygiene Health and Safety Drug Administration Person Centred Planning COSHH Fire Safety Clover House Page 30 Stress Management Principles of Care Challenging behaviour Your Role as a Professional Infection Control All training is up to National Vocational Qualification (NVQ) standard and is underpinned by the Learning Disability Award Framework (LDAFF) Each member of staff has a training booklet, which is completed once there is evidence that the member of staff is competent in the relevant aspect of care. The home management team includes an individual whose role is to ensure that the service users Person centred Plans can be implemented by having a staff team with the skills to meet the service users needs. Staff National Vocational Qualification units are chosen in line with the service users needs. National Vocational Qualification training is done in house. The training manager in the home has the following qualifications; National Vocational Qualification 4 in Care National Vocational Qualification 5 Operational management Registered managers Award Degree in Health and Business Management And is currently undertaking training to obtain a Masters Degree in Social Service Management. The staff team has been increased since the last inspection to meet the needs of a service user recently admitted to the home. There is now a staff member employed each night at Clover House on wakeful duty, with the Proprietor on call in their home across the rear garden from Clover House. There is an inter- com system between the two houses.Clover HousePage 31 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 4 Key findings/Evidence Standard met? This standard is met at Clover House in the ways previously stated in the above section. There is a recruitment policy and procedure in place. Inspection of two staff files demonstrated that application forms are completed, which include a medical declaration. Two written references are evident as are copies of passport and an identifying photograph. Criminal records Bureau (CRB) clearances are evident for all care staff.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? The inspector found evidence that the service users` individual needs and joint needs are met by appropriately trained staff. The home has a training and development plan. The home is utilising the British Institute for Learning Difficulties B.I.L.D induction and foundation framework, which is specific to the care of people with a learning disability. This a Learning Disability Award Framework-accredited training to provide underpinning knowledge for progress towards National Vocational Qualification. 4 of the current staff have achieved the National Vocational Qualification level 3 3 others of the current staff have achieved the National Vocational Qualification level 2 The other staff are currently undertaking training to obtain an National Vocational Qualification. The comments already made under standard 33 are relevant here and further evidence of this standard being exceeded.Clover HousePage 32 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The inspector viewed the staff files that incorporate their appraisals, which are held at regular intervals (2 monthly or sooner if necessary). These are carried out for each individual member of staff. The appraisal system includes; an initial employee appraisal (carried out at the end of the probation period if not required sooner.) appraisal outcome, followed by a 2 monthly appraisal and review. There is also a Staff Handbook.Clover HousePage 33 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES4 Key findings/Evidence Standard met? The following list of training/qualifications achieved are evidence that this standard is exceeded by Mrs Maria Bradley; The Registered Managers Award NVQ Level 4 care NVQ Level 4 Management Work base assessor NVQ Internal verifier NVQ D32, D33, D34 Trainer in moving and handling RSA in counsellingClover HousePage 34 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Inspector found this standard to be met by direct observation at the time of the visit and by examining the records in the home. The staff and service users confirmed this standard is met. The management reward innovation through their pay structure.Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 4 Key findings/Evidence Standard met? The home uses a service users questionnaire, which all service users complete. There are also service users meetings. The service users review of each member of staff also is evidence of how the quality of the service is monitored. The addition of a suggestion box has given the service users another avenue for airing concerns or making suggestions Service users have individual plans and goals are set in a defined manner. A member of the management team has undertaken training in the Techniques of Internal Quality Systems Auditing There was evidence that policies and procedures are reviewed on a regular basis in light of changing legislationStandards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The homes policies and procedures comply with the requirement of this standard and are reviewed on a regular basis at a pre determined date or sooner if legislation requires this.Clover HousePage 35 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? Viewing the policies and procedures, risk assessments and staff training records, including the protection of individuals from abuse, evidenced this standard as being met. Person Centred Plans were viewed as part of this visit Medication records were also viewed and found to be up to date and accurateStandard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 4 Key findings/Evidence Standard met? The home has copies of relevant legislation, seen by the inspector This standard was evidenced via staff training records, including training in recognising and protecting from abuse. All accidents are recorded and reported as required. A new Fire Risk assessment booklet was viewed Health and Safety Risk Assessments were also viewed and reflected how to ensure the environment is safe. These have been drawn up in line with current legislation and others as deemed appropriate by the service users. These are extensive documents which improve the assessment of risk. The following rules were drawn up by the service users; `No smoking in our home `All staff must receive fire safety training `Do not tamper with Fire extinguishersClover HousePage 36 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This Standard was assessed and fully met during the previous inspectionClover HousePage 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureClover HousePage 38 Public reports It should be noted that all CSCI inspection reports are public documents.Clover HousePage 39 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 31st July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and an action plan are available at the area officeAction taken by the CSCI in response to provider comments: Clover House Page 40 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 4th October 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Clover HousePage 41 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Clover House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Clover House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Clover HousePage 42 Clover House / 31st July 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000009695.V141923.R01© This report may only be used in its entirety. 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