Inspection on 23/05/05 for Clover Residents

This inspection was carried out on 23rd May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Clover Residents 18/09/07

Clover Residents 27/04/06

Clover Residents 12/01/06

Clover Residents 13/10/04

Clover Residents 24/05/04

Clover Residents 01/12/03

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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 Gavin Thomas Unannounced 23 May 2005 at 2pm & 3 June 2005 at 10am 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 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 Stationary 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 G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clover Residents Address 2 Dorchester Drive, Bedfont, Middlesex TW14 8HP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 893 1123 denise@cloverhomes.freeserve.co.uk Ms Deborah Selley Denise Avril Pryme Care Home 3 Category(ies) of Learning Disability (0), Mental disorder registration, with number exclusing learning disability or dementia (0) of places Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Only one named service user may be accommodated under the category of MD as agreed by the NCSC on 13/12/04. Date of last inspection 13 October 2004 Brief Description of the Service: Clover is a three bedded home for three service users. It is registered for people with learning disabilities. A category of registration has been approved to accommdoate one named service user only with a mental health diagnosis. The home is a detached below, 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 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. These facilities may also be used by service users. There is a small garden around the bungalow with seating. The home was fully occupied at the time of this inspection. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Although the retention of staff records had improved, this could be improved upon, by ensuring that evidence of all training undertaken by staff is retained at the home. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 6 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 G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 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 standard(s) 1, 4 & 5 Information presented to service users was plain and simple. Where appropriate, signs, symbols and pictures are used. The content of the Statement of Purpose had improved. However, this document did not include details of some of the good practice systems currently in place. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The Statement of Purpose had been update since the last inspection. However, the following sections must include further details: • Criteria for admission to the home. • Supporting service users in maintaining their religious beliefs. • Supporting service users in maintaining contact with significant others. • The arrangements made for respecting service users’ privacy and dignity. The three service users were in receipt of a copy of the Service User Guide. Written contracts were in place between the home and service users. An admissions policy was in place. This policy included details for introductory visits to the home. The home has maintained a stable service user group for a considerable length of time. The Registered Manager said that prospective Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 9 service users would be introduced to the home in accordance with their needs and wishes. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 A good care planning system was in place. This included the involvement of service users. Staff have a good understanding of service users needs. Staff are provided with the information they need to satisfactorily meet service users needs. EVIDENCE: Care plans were in place for all service users. Associated care planning documents were in place in accordance with individual service users needs. Where possible service users agree and sign their care plans. Care plans are reviewed every six months and at other times when necessary. The care plan reviews were comprehensive and included any changes to service users’ health and welfare. Service users are encouraged to make decisions about their own lives. One service user said that they could talk to any of the staff about their wishes and feelings. Communication systems were in place to enable service users to make decisions about their own lives. Outcomes of service users decisions were included in their care plans. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 11 A risk management policy was in place. All risk assessments examined were reviewed regularly. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 & 15 Links with the community are good. The home promotes individuality when supporting service users’ social and educational opportunities. EVIDENCE: Very clear guidelines were in place for service users’ participation in practical life skills. The Inspector observed two service users participating in tasks at the time of the inspection. Varying levels of staff support is provided to enable service users to complete their tasks successfully. The three service users were engaged in a variety of activities throughout the week. Activities included weekly meetings with social groups, activity clubs and sport. Service users are encouraged to participate in community-based activities as often as possible. One service user said they would like to go the pub on weekends. The Registered Manager said this choice is currently available to service users. Service users are supported to maintain their hobbies and interests. This was observed at the time of the inspection. Service users have annual holidays. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 13 Holidays are taken with other members of the household, relatives or social clubs. One service user was on holiday with relatives on the first day of this inspection. The home continues to support service users in maintaining positive links with families and friends. Professional advice is sought if supporting service users to develop and maintain intimate personal relationships. Service users may entertain visitors in their bedrooms. The Registered Manager said that the office would be available for private meetings if required. A visitor’s policy was in place. This policy was being updated at the time of the inspection. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Personal support is offered in such a way as to promote service users’ privacy, dignity and independence. The health needs of service users are well met. The medication in this home is well managed promoting good health. EVIDENCE: Service users personal care support needs were set out in their care plans. These details were specific and well written. The Community Team for People with Learning Disabilities provides the home with professional advice and support. This includes input from the Speech and Language Therapist, Community Nurses and the Psychologist. Service users have input from the Psychiatry Department at West Middlesex Hospital. Service users continue to receive primary health car treatments including chiropody, dental treatments and Opticians. The Registered Manager confirmed that all service users were registered with a GP. Service users health needs were set out in their care plans. Associated guidelines were in place for supporting individual service users. These guidelines are drawn up with the advice and guidance from health care professionals. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 15 A policy on the management and administration of medication was in place. Routine Pharmaceutical audits are carried out. The Medication Administration Records and storage of medication were satisfactory. Records for the ordering, receipt and disposal of medications were in place. The Registered Manager said that staff attended medication in training in March 2005. The home was waiting for written confirmation from the Pharmacist who delivered this training. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 A detailed complaints procedure was in place. Arrangements for protecting service users from possible risk of harm or abuse were satisfactory. EVIDENCE: A complaints procedure was in place. This procedure now includes the contact details for the CSCI. A new format has been introduced for recording complaints. The Registered Manager said that the home had not received any complaints since the last inspection. The complaints procedure was also available in a format suitable for service users. One service user said that they would talk to either of the Proprietors if they had any concerns. The service user said they were very happy at the home and did not have a need to complain. An adult protection policy was in place. The home was also in receipt of the Department of Health No Secrets guidance document. The Registered Manager said that staff were familiar with the procedures for the safety and protection of service users. Staff attended in – house training on adult protection in February 2005. The Registered Manager said that the home had consulted with the Local Authority Adult Protection Coordinator about the course content. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24, 25, 26 & 27 The standard of the environment within this home is good providing service users with an attractive, spacious and homely place to live. Good quality furniture and fixtures are provided. EVIDENCE: The home was very clean and well presented throughout. All rooms inspected were bright, airy and free from offensive odours. New flooring had been laid in the kitchen and lounge/diner. The décor, fixtures and furniture were satisfactory. The location of this home offers easy access to local amenities. The home is also in keeping with local ambience. This home does not use any form of CCTV. A planned maintenance and renewal programme for the fabric and decoration of the premises was in place. This was included in the annual development plan. The three service users are accommodated in single bedrooms. Service users are involved in selecting colour schemes and furniture for their bedrooms. One bedroom inspected was personalised and homely. The service user did express an interest in having the free standing shelving unit removed from their bedroom. This was referred to the Registered Manager for discussion with the service user. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 18 The home has a total of two toilets, one bath and one shower. Although one toilet and the shower are situated in the office/sleeping – in room, service users have access to these facilities. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 Retaining evidence of recruitment check at the home for individual staff has improved. The procedures for ensuring that evidence of all staff training carried out and achieved still requires attention. EVIDENCE: Recruitment policies and procedures were in place. Staff personnel files are now retained in the home. All staff had been issued a contract and terms and conditions of employment. The home had a total of seven staff. The team was made up of both male and female staff. The Registered Manager said there were no staff vacancies at the time of this inspection. Some of the staff also works in another home owned by the organisation. Recruitment records for two staff were examined. Recruitment checks were in keeping with the criteria as set out in Schedule 2 of the Care Homes Regulations 2001. The Registered Manager was advised that health declarations should be signed in full and dated by all staff. A training programme was in place. This programme was included in the annual development plan. Details about the Learning Disability Award Framework training were also included in the annual development plan. Individual staff training and development assessment and profiles were not in place. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 20 Certificates for some of the training undertaken by staff were not available on individual staff files. The Registered Manager did explain that in some cases, copies of certificates were retained in another establishment owned and managed by the organisation. Subsequent to this inspection, the Registered Manager informed the Inspector of the difficulties in obtaining certificates for Food Hygiene training. The Registered Manager was required to confirm this in writing to the CSCI. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39. 40 & 42 The Registered Manager has a clear development plan and vision for the home. Further evidence is required to fully demonstrate how the home’s performance is reviewed. Health and safety systems were well maintained. However, the home did lack sufficient evidence to confirm different types of health and safety training undertaken by the staff team. EVIDENCE: The home was working towards the Investors In People award. A quality assurance policy was in place. A full quality assurance and monitoring system was not in place. The home was in the process of working towards this. Staff surveys had been devised but not implemented. Service users surveys completed on their behalf by their representatives. The results of these surveys are still to be published. An annual development was in place. This plan was detailed and comprehensive. A scheduled review date for this plan should be decided upon. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 22 Policies and procedures in place were reviewed and updated regularly. Health and safety monitoring systems were in place. These included weekly pest control checks, weekly checks on the fire detection system and general safety checks. Fire safety measures were in place. Fire drills are carried out every three months. The record of fire drills must include the duration of fire drills and a section to record any details for follow up, pending on the outcome of each fire drill. The fire risk assessment was devised in September 2003. This assessment must be revised and where necessary, updated. A floor plan was not in place. This must be devised and implemented. Fire safety signage was displayed throughout the home. The Registered Manager reported that two recommendations made by the Fire Officer had been met. The Health and Safety officer inspected the premises in February 2004. The Environmental Health officer inspected the premises in January 2005. Reports for both inspections were positive with no recommendations made. Records examined confirmed that gas, electrical and fire appliances are routinely tested by approved contractors. The electrical and wiring installation test was last carried out in December 1998. According to records for this test, the home is not subject to another test of this kind for a period of ten years. Hot water temperatures are tested for the bath prior to use by service users. Records examined indicated that hot water is delivered within a safe range. The hot water for the shower was not being tested prior to use by service users. Although the Registered Manager explained that service users seldom use this facility, the hot water must be tested to ensure it is delivered at a safe temperature at all times. The Registered Manager said that the bath and shower are thermostatically controlled. Documentary evidence must be obtained to confirm this. The Registered Manager confirmed that all staff had attended training in health and safety, fire safety, food hygiene and First Aid. As stated in the section headed “Staffing” of this report, evidence was not available to confirm this training. In accordance with records examined, no accidents had occurred since the last inspection. A legionella test was carried out in July 2004. The results of this test were satisfactory. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 23 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 2 x x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clover Residents Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 3 x 2 x G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 24 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 1 Regulation 4(1)(c ) Schedule 1 Requirement The Statement of Purpose must include further details relating to: The criteria for admissions to the home, Supporting service users in maintaining their religious beliefs, Supporting service users in maintaining contact with significant others and the arrangements made for respecting service users’ privacy and dignity. Individual staff training and development assessment and profiles must be devised and implemented. Evidence of all trainig undertaken by staff must be retained at the home. The quality assurance and monitoring system in place, must be fully implemented. Requirement of 31/1/05 Not Met. The record of fire drills must include the duration of fire drills and a section to record any details for follow up pending on the outcome of each fire drill. The fire risk assessment must be revised and where necessary, updated. A floor plan must be devised and Timescale for action 31/8/05 2. 35 18(1)(a), (c)(i) 17(2) Schedule 4-6(a) 24 31/8/05 3. 4. 35 39 31/7/05 31/8/05 5. 42 23(4)(e) 03/7/05 6. 7. 42 42 23(4)(a) 23(4)(b), 31/7/05 31/7/05 Page 25 Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 (c)(iii) 8. 42 13(4)(c ) implemented. The hot water from the shower 03/7/05 must be tested at regular intervals to ensure it is delivered at a safe temperature at all times. Documentary evidence must be 31/7/05 obtained to confirm that the bath and shower are thermostatically controlled. 9. 42 13(4)(c ) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 34 39 Good Practice Recommendations Health declarations should be signed in full and dated by all staff. A scheduled review date for the annual development plan should be decided upon. Clover Residents G61 G10 s22908 Clover Residents v214192 230505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 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. 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