Inspection on 02/08/06 for Cloverdale

This inspection was carried out on 2nd August 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cloverdale 11/01/06

Cloverdale 03/05/05

Cloverdale 29/11/04

Cloverdale 08/06/04

Cloverdale 19/05/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Cloverdale 95 Anstey Lane Alton Hampshire GU34 2NJ Lead Inspector Debbie Oliver Unannounced Inspection 2 August 2006 10:00 Cloverdale DS0000011907.V298047.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 Cloverdale DS0000011907.V298047.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. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloverdale Address 95 Anstey Lane Alton Hampshire GU34 2NJ 01420 544118 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) ILIACE Limited Miss Charlotte Louise Farr Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 Brief Description of the Service: Cloverdale was registered in May 2000 and is one of a number of Homes owned by Iliace Limited. It is situated in a rural location close to the town of Alton with its range of leisure and shopping facilities. The Home has four bedrooms, a large lounge/diner and a kitchen and laundry area. There is a garden to the rear of the property and a large driveway with provision for both the Home and visitor’s cars. On the 2nd August 2006 the fees for the home ranged from £1,349.24 per week to £1,730.19 per week. Information about the service provided at the home would be made available to potential service users by providing a copy of the home’s service users guide and statement of purpose. A copy of the last inspection report is available in the home. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over five hours. During the visit, records and documents were examined, an opportunity was taken to tour the premises and staff working practice was observed. The inspector met all four service users. Observation enabled the inspector to gain a better understanding of how the needs of service users were being met. There were no service users from ethnic minority groups. What the service does well: What has improved since the last inspection? Fire evacuation has taken place with all staff to ensure they are clear as to their role and responsibilities in such an event. A risk assessment relating to the building has now been completed. Regulation 37 notifications are now being sent to the Commission as needed. The risk assessment relating to one service user and their access to knives has been completed. The carpet on the stairs has now been replaced. Additionally the carpet in the lounge is also soon to be replaced. The manager stated the activities have much improved with less sickness and more staff. Cloverdale DS0000011907.V298047.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. Cloverdale DS0000011907.V298047.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 Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. 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 the service. The home’s systems and procedures ensure the needs of existing and prospective service users are identified. EVIDENCE: One service user was case tracked and had only moved in a few months previous. The assessment included information relating to personal care, health, social skills, academic skills, domestic skills and community living. This information was then used to compile the relevant care plans and risk assessments. Additionally the service users who had lived at the home for a significant period of time had evidence of regular reviews within their plans. The newest service user had a positive transition in to the home including visits to get to know the other service users and ascertain if they liked the home. There was also information in the service users’ plan detailing the visits. On observation throughout the day it was evident staff can meet service users’ needs. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a clear and consistent care planning system in place that adequately provides staff with the information they need to satisfactorily meet service user’s needs and enables them to support service users to make decisions about their lives. Risk assessments are in place and ensure service users are able to take risks as part of an independent lifestyle. EVIDENCE: Two service users were case tracked and the relevant plans contained ‘profile of a client’; this gives information on how the service user should be supported and what they can do independently and what they need support with. Each service user then has a level one care plan that gives more detailed information about the individual. The plans also showed they were being reviewed on a regular basis. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 10 One staff member spoken to said they feel the plans give staff the information they need to support service users. It was apparent throughout the visit that service users are supported to make decisions such as asking staff for a drink using gestures and choosing to relax on the sofa watching television. Service users were also shown choices by staff such as various deserts and they took the one they wanted. One service user spoken to said they helped to choose the colour of the carpet that is due to be laid in the lounge. Daily planners are in pictorial form and the home is about to start using PECS. The service user meeting minutes showed decisions being made such as activities and how they feel about living at Cloverdale. Evidence was seen within the files to support that risk assessments are available and that service users are supported to take risks including swimming and use of the kitchen. A risk assessment is in place for the front door that can only be opened using a card but it needs to include this is not a restriction and is in the best interests of service users. The risk assessment relating to a service user having access to knives has been completed and was seen by the inspector. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities to engage in suitable activities and are part of the local community, so promoting independence and choice. Contact with families is well supported, and nutritional needs of service users are well managed. EVIDENCE: It details in the daily diaries what activities have been undertaken such as visiting the QE2 activity park and watching videos. During the visit service users were seen going out and about such as attending cookery classes. The home uses objects of reference for activities such as a wooden spoon to indicate cooking and the service users respond to this. The manager stated the activities have much improved with less sickness and more staff. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 12 Contact with families is very positive. All service users have regular contact with their families and this is documented in their plans. One service user said they visit their mum weekly. All of the service users also speak with their families by telephone. Service users were seen accessing all parts of the home and staff were seen using appropriate language for service users and asking rather than demanding things of service users. A menu was seen and offered a varied and nutritious diet with space for alternatives as needed. A picture of the meal is put up on the board in the kitchen. On the day of the visit service users were in the kitchen helping with the preparation of lunch. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal, physical and health care needs of service users are well met and the procedure for the receiving and administering of medication is robust ensuring a safe system for service users. EVIDENCE: Care plans show how service users like to be supported in regard to their personal care including what they need help with and what they can do for themselves. There are also clear guidelines for particular health needs such as epilepsy. Staff spoken to confirmed service users have positive input from opticians, general practitioners, dentists and chiropodists and there was evidence in the plans to show this happens. Daily records show visits to health professionals and the outcomes of these visits. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 14 The home has a policy on medication and this is accessible to staff. The medication is kept in a locked cupboard with the appropriate guidelines in place relating to receipt, administration and disposal of medication. Additionally there are guidelines relating to the use of ‘as required’ and over the counter medication. All staff have received training in administering medication and one staff member spoken to said it gave them the skills to administer medication with confidence. There was also a discussion that a running total of ‘as required’ medication should be kept so as to monitor how much an individual is taking during a 28 day period. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for protecting service users and responding to concerns are satisfactory. EVIDENCE: The complaints procedure is available but it could be more accessible to service users. Iliace are in the process of updating their policies and procedures and the manager agreed to pass this information on. The complaints log was also seen and there have been no complaints. Staff spoken to were confident to go to the manager with a complaint or concern. The home has the relevant procedures and policies and all staff have received training in adult protection. The manager agreed to check if the Hampshire Adult Protection Policy is the most up to date one. Staff spoken to said the training has given them confidence in understanding the process. The home is now sending regulation 37 notifications to the Commission as needed. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A comfortable, safe and hygienic standard of accommodation is provided for the service users, which meet their needs. EVIDENCE: The inspector toured the home and it is well maintained and suited to the service users’ needs. It is decorated to a standard that creates a comfortable and homely ambience. The home is well furnished with good quality domestic fixtures and fittings. The tear on the stairs carpet has been repaired with a new carpet being fitted. Additionally new carpet has been ordered for the lounge and a new patio is being planned for the garden. There are also plans to make sure the conservatory gets used as at the moment it is too cold in the winter and too warm in the summer, so it is now used as a junk room. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 17 The laundry room is accessed by going through the kitchen but staff confirmed no laundry is taken through the kitchen whilst food is being prepared. There is a risk assessment in place detailing the need for laundry and food preparation to be done at separate times. Protective equipment is used and is stored in the laundry room. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has procedures and systems in place that ensure staff are properly recruited and that there is always enough staff on duty. The training in place shows staff have the necessary skills and knowledge to meet the complex needs of service users accommodated in the home. Regular supervision for staff ensures they are well supported. EVIDENCE: From observation and discussion with staff members, they have built good relationships with service users and have a good understanding of their behaviours. Two staff were spoken to and they indicated that they have received good training since starting in the home. The training received included autism, epilepsy, food hygiene and health and safety. There were some gaps in the training matrix and the manager confirmed training courses were being booked. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 19 The National Vocational Qualification (NVQ) is now available to all staff and a meeting is being held to explain the course. All the staff in the home with the exception of one want to start their NVQ. Staff spoken to confirmed they receive regular supervision and annual appraisals and that the manager is approachable and easy to talk to. There was adequate staff on duty at the time of the visit and this was confirmed on the rota. The inspector sampled three staff files and they contained most of the necessary information relating to recruitment. The application forms were missing and the manager stated these are kept at head office. It was discussed that if information is kept at head office there still needs to be confirmation in the home it has been obtained. Cloverdale DS0000011907.V298047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well organised home and the quality assurance system ensures service users and their families are able to contribute their views for the development of the home. The system for maintaining the health, safety and welfare of service users is satisfactory. EVIDENCE: The manager has her registered managers award and felt the course helped to develop her. At times the manager felt the support has been limited but with a new regional manager this has improved greatly. Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 21 Senior managers of Iliace visit the home every month to assess the service being provided and time is spent talking to service users. A copy of this visit it sent to the Commission. Families are fully involved and have been sent questionnaires recently and the manager is waiting on two to come back. These will then be fed back to the regional manager. It was discussed the organisation needs to ensure they feedback to families if there are any issues. Staff discuss their views through supervision and team meetings. The home has objectives for improvement that are set for the year and reviewed on a quarterly basis. NVQ and the use of Makaton are objectives for the coming year. Service user meetings are held to ensure the views of service users are taken in to account. The minutes of the last meeting were seen and service users were asked if they liked living in the home, they all do. The home’s fire alarm system and extinguishers are checked regularly by the maintenance team of Iliace and records are made of these checks. Fire safety training has been provided to staff and they said it was useful and equips them to know what to do in the event of a fire. The fire risk assessment was completed in February and the service has been rated as low risk. The gas and electrics have also been tested and the inspector saw the certificates. The manager agreed to chase up the five year electrical wiring test. Food was suitably stored and daily checks of the fridge and freezer were recorded. There are relevant health and safety policies in the home and staff sign to say they have read them. Accident books were also seen but as the incident is filed away there was no indication on who had the accident and the outcome. Cloverdale DS0000011907.V298047.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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Cloverdale DS0000011907.V298047.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cloverdale DS0000011907.V298047.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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