Inspection on 18/09/07 for Clover Residents

This inspection was carried out on 18th September 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clover Residents 27/04/06

Clover Residents 12/01/06

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 Sarah Middleton Key Unannounced Inspection 18th September 2007 09:30 Clover Residents DS0000022908.V348422.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 Clover Residents DS0000022908.V348422.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. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clover Residents Address 2 Dorchester Drive Bedfont Middlesex TW14 8HP 0208 893 1123 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 Denise Avril Files Denise Avril Files Care Home 3 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning - Disability - Code LD 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 8th January 2007 Date of last inspection Brief Description of the Service: Clover is a three bedded home for three residents. 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 the residents. The bedrooms do not have washbasins. The office/sleeping - in room has its own shower and toilet. There is a small garden around the bungalow with seating. Fees vary and are dependant on the assessed resident’s needs. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previously used term service user will not be used in this inspection report. The term resident will be used and refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.30am-6pm. The Inspector viewed samples of residents’ files, staff employment files and maintenance records. All three residents and two members of staff were spoken with during the inspection. The three residents had assistance to complete postal surveys and one family member also completed a postal survey. Feedback was positive from these surveys. The Registered Manager assisted with the inspection process and had completed an Annual Quality Assurance Assessment, providing information about the home. The requirement from the previous inspection visit had been met and four new requirements were made following on from this inspection. All of the National Minimum Standards were assessed during this inspection. What the service does well: What has improved since the last inspection? The training programme has made every attempt to meet the needs of staff and thus the needs of the residents. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 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.V348422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: There have been no new admissions into the home since the last key inspection. The last resident to move into the home had an assessment completed by Social Services and the home met with the resident to also assess his needs. This assessment was viewed and was a checklist of various areas of the resident’s life, such as his self-help skills, personal care needs and daily living skills. It did not include details of the resident’s health or mental health needs, neither did it allow the assessor to add additional information from the resident, referrer or relative. This was discussed with the Registered Manager who acknowledged that the pre-admission assessment could benefit from being reviewed and updated. The Inspector was satisfied that the Registered Manager will carry this out. The Registered Manager confirmed that any prospective resident would be encouraged to visit the home and to meet with staff and the other residents. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The identified shortfalls in the care plans could pose a risk to the residents. Residents are supported to make daily decisions about their lives. Residents are able to take risks and risk assessments are completed to ensure the staff team are aware of the potential hazards to a resident and/or towards others. EVIDENCE: The Inspector viewed two care plans and daily records. The care plans are reviewed every six months. The reviews were seen and these looked at the significant events relating to areas such as health, medical appointments and social interests. Relatives and residents are invited to reviews and can contribute to the discussions. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 10 One resident has more frequent reviews so that the home can consider and respond to any issues or concerns relating to his needs. The care plans seen did not clearly indicate the residents’ needs, such as personal care or health needs or how these needs were to be met. Furthermore it was not clear what the resident could do independently and where staff would need to guide and support the resident. This was discussed with the Registered Manager and a requirement was made for this shortfall to be addressed. The Registered Manager also needs to be mindful of including the residents’ aims and views and recording relevant comments in the care plan. Guidelines were in place to inform staff how to support a resident when going out into the community and shopping. This could be taken a step further by developing daily routine guidelines for all residents to let staff know the specific likes, dislikes and needs for each resident. Daily contact sheets were seen and recorded the mood and activities the resident had taken part in. The residents do not have independent advocates but all have some level of family contact. Those staff asked could describe how they support and encourage the residents to make daily decisions about their lives, such as how they spend their time and when they want to be alone or with others. One resident has very few items in his bedroom due to the potential risks identified. This has been clearly recorded on his file. Another resident has a long-standing relationship with a person who does not live in the home. Staff monitor the relationship, as there have been some issues and concerns about the relationship. Meetings have been held to consider the best way to support the resident. Although there are issues within the relationship, the home needs to consider the Mental Capacity Act 2005, mentioned later in the inspection report, as the resident could have the capacity to choose how the relationship develops or not as the case may be. The Inspector viewed a sample of risk assessments. For one resident in particular the risk assessments were very detailed, clearly outlining the potential and actual risk towards the resident and towards others. Risk assessments are reviewed every six months or whenever there has been a change in needs. The documentation seen outlined why certain decisions had been made, such as minimal possessions in the bedroom. Other areas considered and noted covered a range of subjects such as aggression towards others and communication difficulties. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to engage in social activities both in the home and in the community. Residents are supported to maintain social relationships. Residents’ rights are respected and recognised. The meal provision is varied and caters for individual needs and preferences. EVIDENCE: Two of the three residents attend the local resource and leisure centre. One resident goes to this centre independent of staff and is picked up at the end of the day. At this centre various activities take place such as day trips, playing golf and pub lunches. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 12 The third resident has one to one support from a member of staff who encourages the resident to take part in activities in the community such as bowling, swimming and daily tasks in the home, such as cooking and cleaning. This resident also attends a Mosque with a member of staff, who has the same religious beliefs as the resident and is therefore able to support the resident with this activity. Occasional day trips are organised, as transport can be arranged with another care home owned by the Registered Manager/Provider. Transport links are good and residents are supported to use all forms of public transport. Activities are planned around what residents are interested in and their individual abilities. Contact with relatives varies, with one resident seeing their relatives on a weekly basis, whilst others have only occasional visits. Members of staff support residents to speak with relatives on the telephone. One resident showed the Inspector the keys they have to the front door and to his bedroom. If residents are able to safely hold onto keys, then these are provided. All residents receive their own personal mail, although all need assistance from staff to read the contents of the mail. The home no longer holds resident meetings, as these did not prove beneficial. Staff were seen to interact with residents throughout the inspection and not exclusively with each other. The Inspector briefly observed a resident being supported to make dinner for all the residents. One resident has specific cultural needs and has a separate fridge and cupboard for his food. Residents choose the meals they would like to eat and this is recorded. Staff monitor the meals to ensure residents are not eating the same foods and fresh produce is available and used wherever possible. Two of the residents preferred foods and dislikes were seen written in the kitchen. Some of the kitchen tile paint was peeling near the sink and cooker and one tile was cracked. Furthermore a fridge salad bowl was cracked and had been taped, these shortfalls were brought to the attention of the Registered Manager, see Standard 24 for further information. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in their preferred way. The health needs of the residents were being met. The identified medication shortfall could pose a risk to residents. EVIDENCE: Residents need different levels of support when managing their personal care. Personal care support is provided in private. One resident spoken with confirmed that he could get up and go to bed when he so chooses. Staff described how sometimes residents need support to wear appropriate clothing. Health needs are met with residents seeing a range of health professionals, such as Psychiatrist, Psychologist and GP. Any medical appointments attended are recorded onto a form that notes any advice or treatment prescribed. One resident is currently being assessed for early stages of dementia. No conclusions as yet have been drawn from the ongoing assessment. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 14 Body charts are completed for all residents to ensure staff monitor any marks on the residents body. Each resident is weighed to enable staff to act on any significant changes. The Inspector viewed the medication in the home and counted a sample of medication. Medication is locked in a secure cupboard, but it is not a metal medication cabinet. No residents self-medicate and there were no controlled drugs in the home at the time of the inspection. Medication that was counted was correct. Staff count all loose medication that is in boxes and bottles every day. Records were seen that these checks are carried out. The Inspector advised the Registered Manager to obtain a more secure counting tool to ensure loose medication from a bottle is counted safely and correctly. The Inspector noted that for one resident, who goes out most days with a member of staff, his afternoon Medication Administration Record had been signed for, when it had not actually been given by the member of staff at the time the record was signed. The home had seen this as good practice as it informed other staff that the medication was not in the home. The Inspector spoke with the Registered Manager as Medication Administration Records must only be signed when the member of staff has actually witnessed the resident take the medication there and then in front of them. The home needs to have a procedure when this situation arises, such as recording on back of the Medication Administration Record when medication has been taken out of the home. Once the member of staff returns they can then sign the record to confirm it was administered correctly. Some medications can be taken earlier or later than prescribed, therefore the Registered Manager could liaise with the GP and/or Pharmacist to see if this would be a safe alternative. A requirement was made, following discussions with the Pharmacy Inspector, for the home to address this shortfall. The Pharmacist had not audited the medication systems in the home since 2005, despite the Registered Manager asking for this to be carried out. This has now been booked for October 2007 and needs to be carried out on an ongoing basis. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views would be listened to and acted on. Systems are in place to safeguard residents from abuse. EVIDENCE: The Inspector spoke with one resident who confirmed that he would speak with the Registered Manager if he wanted to raise a concern or complaint. Copies of the complaints procedure were seen in two of the residents’ bedrooms. The home has not received a complaint in several years. Documentation is available for staff to complete should a complaint be made. There have been no adult abuse investigations or concerns in the home. Staff receive regular training on this subject. Residents are not able to manage their own finances. The Inspector counted two residents’ finances. All financial transactions are recorded and receipts are obtained. The money checked was correct at the time of the inspection. The residents’ money is counted and checked on a regular basis to ensure there are no errors. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home needs to be welcoming and homely for the resident to live in and particular areas in the home were identified as needing attention. Overall the home was clean and hygienic. EVIDENCE: The Inspector carried out a tour of the home and all rooms were viewed. Overall the home is welcoming and bright, however there were shortfalls identified. • As mentioned earlier, the kitchen tile paint was peeling off the walls in certain areas of the kitchen and one tile was cracked. • In one resident’s bedroom the chest of drawers were in need of repair and the resident said he had lost the key to his lockable unit. The Registered Manager said the resident’s possessions had been fixed in the past when items had been broken. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 17 • In another resident’s bedroom there was a bulb but no light fitting attached to the ceiling light. • The seal around the bath was beginning to get mouldy and needed replacing. • The fridge plastic salad bowl had cracks and needed replacing to avoid bacteria and germs spreading. The above issues were brought to the attention of the Registered Manager and a requirement was made for these to be addressed. The staff and residents keep the home clean and at the time of the inspection the home was clean and tidy. There were no unpleasant odours. Residents have a set day to do their personal laundry with the assistance of staff. The laundry room is located in a room leading off from the kitchen. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 18 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): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place and protect residents. The training programme in place meets the needs of the staff team and consequently the needs of the residents. EVIDENCE: Four of the support workers have completed NVQ level 2 and one is interested in completing NVQ level 4. The staff team is small and staff stated the team works well together in the interests of the residents. Those staff spoken with could describe the needs of the residents and how best to support them. The staff team have an awareness of the cultural needs of the residents and aims to meet these needs with assistance, where necessary from others, such as relatives. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 19 The staff team meet every two months and overall staff said they could rely on receiving support and advice if needed. For the most part of the day there are two staff working with the residents. There is always someone on call if additional help is needed. The home does not use external agency staff and if there are vacant staffing hours to cover, then either permanent staff or bank staff work. At times members of staff from the other registered care home, owned by the same Registered Providers, work in the home. The Registered Manager must be mindful to ensure when this occurs information about these workers from the other home are available to view, such as employment details and information on training attended. The home has a low staff turnover, with only two staff leaving the team since the last inspection. The Registered Manager has been active in seeking a suitable member of staff to work with one resident who has particular communication and cultural needs. This has been achieved to the best of the home’s ability and is always being reviewed to ensure it is working in the resident’s best interests. The Inspector viewed a staff employment file on the most recent person to join the staff team. This file contained the information required by the Care Homes Regulations 2001. Discussions took place with the Registered Manager, as the references seen were not from the member of staff’s most recent employer. It would be good practice to seek information from the most recent employer, as they would have up to date information on this person. Where there are particular reasons that this cannot be obtained a record should be made as to the reason for seeking alternative references. The Inspector viewed the induction the home uses for new members of staff. This document is used throughout the weeks the new member of staff becomes familiar with working in the home. The induction looks at various areas, such as values, policies and procedures and teamwork. New staff have the opportunity to shadow existing members of staff to ensure they can observe daily routines of the home. The Inspector viewed training records. Overall staff were up to date with the mandatory training, such as Health and Safety and moving and handling. Additional training in subjects such as Autism and dementia were also being offered to staff. Those staff asked were happy with the training they received. The Inspector discussed the Mental Capacity Act 2005, mentioned earlier in the report. This is important for the Registered Manager, staff and if appropriate residents to be aware of. Staff should receive information and training on this legislation and how to implement it into daily working practice. A recommendation was made for this to be provided. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 20 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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home. Quality assurance systems are in place to monitor the care provided in the home and to seek the views of residents and relatives. Overall there are good systems in place for the management of health & safety, however the shortfall in radiators not being covered could pose a risk to the residents. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered Manager is also one of the Registered Providers. She has obtained NVQ level 4 and attends periodic training to ensure she maintains the skills and knowledge needed to manage the home. Staff commented on how they could seek support and advice from the Registered Manager. Surveys are sent to relatives, residents and health professionals and the Registered Manager considers the responses. The Registered Manager had also completed a quality assurance report that considers different areas of the home such as environment, and daily living. The monthly report was also viewed and this considers staffing, activities and future aims and objectives. A sample of servicing and maintenance records were viewed, such as Gas safety record and fire equipment and these were found to be up to date. The fire officer had visited the home in January 2007 and had viewed the fire risk assessment. The recommendations made to the Registered Manager to have a plan of the fire exits and location of fire extinguishers had been carried out. The fire risk assessment viewed did not cover the risk the kitchen area could pose to residents and staff. This was brought to the attention of the Registered Manager, as this needs to be added to the risk assessment. The Inspector was satisfied that the fire risk assessment would be reviewed and updated as and when the Registered Manager deemed it necessary. There was a small fire in one of the resident’s bedrooms. Staff had taken appropriate action and the relevant fire authorities had attended the fire but had not visited the home since then. The home holds regular fire drills and staff attend fire awareness training. The environmental risk assessment seen needed to consider the areas where residents could be at risk in the home and garden. The Registered Manager will complete this assessment and this will be looked at during the next inspection visit. The Inspector noted that all of the radiators, except the one in the bathroom had not been covered. As the needs of the residents change, in particular two of the residents, who are getting older, areas of the home need to be considered and adapted to safeguard the residents. The radiators felt by the Inspector were hot to touch and a requirement was made for this to be addressed. Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15(1) Requirement Timescale for action 31/10/07 2. YA20 3. YA24 4. YA42 In order for staff to meet residents needs, care plans need to clearly indicate the residents’ needs and how these needs are to be met. 13(2) To safeguard residents, Medication Administration Records must only be signed when medication has actually been given. 23(2)(b)(d) In order for the home to be welcoming and meet residents needs, all areas in the home must be maintained to a good standard. 13(4)(a)(c) To safeguard the residents, all radiators must be covered. 18/09/07 30/11/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations It is recommended that all staff receive information and training on the Mental Capacity Act 2005. DS0000022908.V348422.R01.S.doc Version 5.2 Page 24 Clover Residents Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Clover Residents DS0000022908.V348422.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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