Inspection on 12/01/06 for Clover Residents

This inspection was carried out on 12th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clover Residents 18/09/07

Clover Residents 27/04/06

Clover Residents 23/05/05

Clover Residents 13/10/04

Clover Residents 24/05/04

Clover Residents 01/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Clover Residents 2 Dorchester Drive Bedfont Middlesex TW14 8HP Lead Inspector Mr Gavin Thomas Unannounced Inspection 15:10 12 January 2006 th Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 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 Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 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. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clover Residents Address 2 Dorchester Drive Bedfont Middlesex TW14 8HP 0208 893 1123 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) Ms Deborah Selley Ms Denise Pryme Denise Avril Pryme Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Clover is a three bedded home for three service users. It is registered for people with learning disabilities. The home is a detached bungalow, situated in a quiet cul-de-sac. It is within easy walking distance of Bedfont, where there are shops and public transport links. Hounslow town shopping centre and Feltham leisure facilities can be easily accessed from the home. Accommodation includes a large lounge/dining room and three single bedrooms. There is one bathroom with a toilet for three service users. The bedrooms do not have washbasins. The office/sleping - in room has its own shower and toilet. There is a small garden around the bungalow with seating. The home had a vacancy for one service user at the time of this inspection. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 2.5 hours. During this time, the Inspector met with the Registered Manager and spoke with the two service users and staff member on duty. Both service users were smart in their appearance and said they were well. The Inspector observed both service users carrying out tasks around the home with enthusiasm and great care. It was positive to observe the staff member carrying out domestic tasks with the service users and not for them. The atmosphere in the home was friendly and welcoming. This inspection took place on a cold day. The home was well heated throughout. What the service does well: What has improved since the last inspection? The Statement of Purpose is much improved. The presentation of this document is now more user friendly and contains all the relevant information required under Schedule 1 of the Care Homes Regulations 2001. Evidence of staff training had improved. Attendance records and certificates of training undertaken within the last year were available on staff files. Out of the nine requirements made at the previous inspection, seven requirements were met, one was partially met and one was not met. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Procedures for conducting initial assessments with prospective service users were satisfactory. However, the outcomes of assessments must be confirmed in writing to service users. EVIDENCE: The Registered Manager confirmed that all referrals for prospective service users are made via the Placing Authority. The home obtains copies of needs led assessments for all prospective service users from the Placing Authorities. The home carries out subsequent assessments with prospective service users, which includes consultation with the service user and/or their relatives, consultation with the Placing Authority and where appropriate, significant others such as the Community Team for People with Learning Disabilities (CTPLD). Currently, the home does not confirm in writing to the service user that having regard to the assessment, the care home is suitable for the purpose of meeting their needs in respect of their health and welfare. This must be implemented for service users admitted to the home in the future. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Good quality care plans were in place. However, care plans must be reviewed at more regular intervals. EVIDENCE: Care plans were in place for both service users. Both care plans were well written and included procedural guidance for supporting service users with specific tasks. Care plans are currently reviewed annually. Reports for the reviews were detailed. However, the home must implement a system to review and where necessary update the care plans at least every six months. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The systems for service users consultation are good with a variety of evidence that indicates service users’ choices and preferences are sought and acted upon. The meals in this home are good offering both choice and variety. EVIDENCE: Both service users have keys to their bedrooms and the front door of the home. The Registered Manager said that service users are given their mail unopened. One service user confirmed this. Staff assist service users in opening and/or reading their mail if requested. Staff maintain positive relationships with both service users. This was observed at the time of the inspection. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 11 Service users carry out tasks around the home such as assisting to cook, clean, empty refuse bins and shopping. One service user confirmed this. The Inspector also observed staff and service users carrying out domestic tasks together. Service users choose when to be alone or in company. Rules on smoking, alcohol and drugs are agreed verbally between the home, service users and staff. These rules should be confirmed in the form of a written policy. Menus are very seldom agreed in advance. Menus are often agreed with service users on a daily basis. The main meal of the day varies. Service users normally have their main meal at their day centres. The Inspector observed service users discussing their choices for an evening meal with staff. All foods are purchased locally. Service users are involved in food shopping and food preparation. A record of food served was in place. This record was well maintained and up to date. The dining facilities were domestic in size and judged to be of good quality. With the exception of service users preferences and choices, the home was not catering for any special diets for health reasons at the time of this inspection. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 Matters relating to dying and death are approached sensitively but where possible, further details should be obtained for the reasons as stated below. EVIDENCE: The Registered Manager explained that the home’s approach to the management of dying and death would be approached with great care and only discussed if service users and/or their relatives are willing to engage in conversation about this topic. The Registered Manager said that she had approached families in the past about preparing wills with or on behalf of service users. The Registered Manager was advised to further consult with service users and/or their relatives and where possible, obtain details on service users last wishes including observation of religious and cultural customs. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Good practice systems were in place to promote and maximise service users safety and protection. EVIDENCE: Adult protection policies and procedures were in place. The home was also in receipt of associated adult protection documents such as London Borough of Hounslow’s adult protection procedures and the Department of Health No Secrets guidance document. Staff last attended adult protection training in September 2005. Refresher training was scheduled for January 2006. The home was aware of the adult abuse awareness week, which is being organised by the London Borough of Hounslow in February 2006. The Registered Manager confirmed there were no concerns regarding the safety or protection or both service users. The Registered Manager did explain that the golf bag was causing bruising on one service user’s arm. This matter was dealt with appropriately. One service user spoken to said they felt safe in the home. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. Evidence of infection control policies and procedures must be improved upon. EVIDENCE: All parts of the home inspected were clean, hygienic and free from offensive odours. The Inspector observed staff and the two service users carrying out good hygiene practices such as cleaning door knobs with disposable anti bacterial wipes. One service user who was emptying the refuse bin was also wearing disposable latex gloves. This is judged to be good practice. The laundry facilities are situated in the utility room. A new washing machine was installed in 2005. Due to the layout of the home, the utility room is accessed via the kitchen. The Registered Manager confirmed that soiled clothing and linen is taken to the utility room via the kitchen in lidded laundry bins. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 15 Hand washing facilities are provided in the kitchen, bathroom and staff bathroom. Some guidance on infection control was included in the health and safety policy. However, this guidance was not written in full and did not take into account all aspects of safe working practices with regards to infection control. This must be developed and made known to the staff team. An approved contractor carried out a legionella test in July 2004. The results of the test indicated that no legionella bacteria was detected. Seven recommendations were made by the contractor with regards to water storage and safety. No action had been taken by the home to address the recommendations. The Registered Manager was required to consult with the contractor and act on the recommendations made. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Staff have a good understanding of service users’ support needs. This is evident from the positive relationships observed between staff and service users. Staff are well supported the Registered Manager. EVIDENCE: All staff attend formal one to one supervisions with the Registered Manager every two months. The frequency of formal one to one supervisions meets with the criteria as set out in standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65). The Registered Manager had devised a programme for staff supervisions and appraisals throughout the year. This is judged to be good practice. All staff also have an annual appraisal of their work. Records of completed supervisions and appraisals examined were well written. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 The home must improve upon the systems of self-review and quality assurance and monitoring systems. EVIDENCE: The home was working towards the Investors In People award. Surveys completed by/on behalf of service users were seen. The home is required to publish the results of these surveys. The Registered Manager had produced an annual training report. An annual development plan was in place for the previous year. This plan must be revised and updated and/or a new annual development plan must be produced for this year. The home is required to devise and implement quality assurance and monitoring systems, which takes into account the criteria as set out in standard 39 of the National Minimum Standards for Care Homes for Adults (18-65). This requirement is restated from the previous inspection. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 18 The record of fire drills now include the duration of the drills and a section for any action to be taken pending on the outcome of each fire drill. A fire risk assessment has been devised and implemented. A fire emergency route planner has also been devised and kept on file. The Registered Manager was advised to display a copy of the planner with other fire safety information. The home is now in receipt of documentation to confirm that the bath is fitted with a thermostatic control. Records seen confirmed this. The home does not have any documentation to confirm if the shower in the staff room is fitted with a thermostatic control. The Registered Manager was of the opinion that this facility was not fitted with a thermostatic control. Hot water temperatures are only taken for hot water delivered to the bath. The Inspector was informed previously, that on rare occasions, service users might use the shower. However, given that there is no evidence to confirm if a thermostatic control is fitted to the shower and temperatures of the water are not taken, the Registered Manager was advised that unless safety precautions are put into place, service users must not use the shower. Although the shower is mainly used by staff, the Registered Manager should arrange for the hot water to be tested periodically. This requirement is restated from the previous inspection. The home should also consider having a thermostatic control fitted to ensure that the temperature of the hot water is delivered at a safe temperature. Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 2 17 Standard No 31 32 33 34 35 36 Score x x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clover Residents Score x x x 2 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000022908.V261252.R01.S.doc Version 5.0 Page 20 Yes 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 YA2 Regulation 14(1)(d) Requirement Timescale for action 28/02/05 2 YA6 3 YA30 4 YA30 5 YA39 6 YA39 The home must confirm in writing to prospective service users that having regard to the assessment, the care home is suitable for the purpose of meeting their needs in respect of their health and welfare. 15(2)(b)(c)(d) Service users care plans must be reviewed and where necessary updated at least every six months. 13(4)(c) Policies and procedures on infection control must be developed and implemented with the staff team. 13(4)(c) Action must be taken to address the seven recommendations made by an approved contractor regarding water storage and safety. 24(1)(a)(2) The results of surveys completed by/on behalf of service users must be published. 24 The home must implement full quality assurance and monitoring systems. (Requirement of 31/8/05 Not Met). DS0000022908.V261252.R01.S.doc 31/03/06 31/03/06 28/02/06 31/03/06 31/03/06 Clover Residents Version 5.0 Page 21 7 YA39 24 8 YA42 13(40(c) The annual development plan must be revised and updated and/or a new annual development plan must be produced for this year. The home must not permit service users to use the shower in the staff room until such time when proper safety precautions are installed to prevent scalding. 31/03/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 1 2 Refer to Standard YA16 YA21 YA42 Good Practice Recommendations Rules on smoking, alcohol and drugs should be produced in the form of a written policy. Where possible, the home should obtain details of service user’ last wishes in the event of death including observation of religious and cultural customs. The home should consider having a thermostatic control fitted to the shower in the staff room to ensure that the temperature of the hot water is delivered at a safe temperature. Hot water from the shower in the staff room should be tested periodically to ensure that it is delivered at a safe temperature. 3 YA42 Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clover Residents DS0000022908.V261252.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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