Inspection on 03/05/05 for Cloverdale

This inspection was carried out on 3rd 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 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 02/08/06

Cloverdale 11/01/06

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 Pat Hibberd Unannounced 03.05.05 09:00 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. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Cloverdale Address 95 Anstey Lane Alton GU34 2NJ Hampshire 01420 544118 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) ILIACE Limited CRH 4 Category(ies) of LD registration, with number of places Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29.11.04 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 Homes and visitors cars. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and was the first unannounced inspection of the 2005/2006 inspection programme. Twelve areas of service provision were assessed on this occasion with eight areas of improvement identified and required to be addressed by the Manager. Full details can be found at the end of this report. The inspection included a tour of part of the Home . Discussions were held with the Home’s Manager, Responsible Individual for the Organisation, two Service Users and two members of staff. Due to the varying needs of Service Users the objective of the inspection was to focus on the experiences of individuals through discussion (for those who are able) observation and inspection of documentation relating to care provided . Two Service User files were viewed and their care provided by the Home in all areas of their life assessed and discussed with both the manager and staff. Since the last inspection the Commission have received an application for registration from the manager. The application is currently being processed. What the service does well: The Organisation has designated staff who are responsible for organising activities for Service Users . It was evident from Service Users daily planners that they are offered a range of community activities which are person centred and appropriate to individual needs. The staff team were seen to communicate appropriately with Service users using Makaton sign language and verbal communication and during discussions held demonstrated a good understanding of the needs of individuals. Training provided by the Organisation is of a good standard with all new staff undertaking a thorough induction . Three weekly training is provided on an ongoing basis with job coaching offered to staff if requested . The Learning Disability Award Framework (LDAF) is being introduced for all staff. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: It was evident from two Service User files viewed that care plans and risk assessments are required to be updated and shared with staff to ensure a consistent approach is given to care provided. For Service Users prescribed “ as required “ medication written guidelines must be in place for staff to ensure they are clear as to when they should administer and why. Guidelines regarding “de-escalation methods “ to be used prior to the administration of “as required “ medication prescribed for self injurious or aggressive behaviour towards others must be written and shared with staff in relation to one Service User. Systems must be in place for the safe storage of food. Menus must be produced in a format that is suitable to the needs of Service User’s accommodated. Staff must undertake moving and handling and food hygiene training. All staff must receive training in protecting Service Users and be familiar with the Hampshire Adult Protection Policy and Procedure and it’s application to service delivery. Following any incident of abuse consultation must take place with Social Services under the Protection of Vulnerable Adults policy and procedure. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 7 The manager must ensure the Commission are notified of any event in the Home which adversely affects the well being or safety of any Service User’s. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 8 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 Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 9 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) No Standards were assessed on this occasion. EVIDENCE: Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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,and 9 Service Users are encouraged to make choices about their daily life. The arrangements for care planning are not consistent for all Service Users to ensure their care needs are met and they are not placed at risk. EVIDENCE: Service Users are encouraged to make decisions about their lives through menu planning, personalising their bedrooms and, identified needs in relation to how they choose to spend their day. Service Users meetings are not held as the manager advised that it would be difficult engaging individuals in a meeting together. Two Service User files were viewed which indicated that care plans and risk assessments had not been updated in all areas of their lives. The manager confirmed that whilst she had read the files for all four Service Users accommodated she had not had time to update the information collated and Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 11 documented by the previous manager. Some of the information related to care plans/ risk assessments completed in April 2004. For example it was evident from an incident form completed that a Service User had burnt themselves from hot water in the kettle whilst making themselves a drink in the kitchen. A risk assessment had not been completed and the manager could only confirm that staff had been verbally informed that the individual was to be supported at all times when in the kitchen. Another example related to there being no guidelines for staff in relation to how to de escalate “challenging” behaviours in relation to one Service User. One staff member confirmed that they had been verbally told to administer“ as required medication when the Service User exhibited self injurious or aggressive behaviour towards staff or Service Users. They had not received any guidance as to how to manage the behaviour. The behaviour of the individual was not discussed with Service Users . However, the manager confirmed that Service Users can exhibit anxiety following a bout of aggression . The manager further confirmed that there is no pattern to the frequency of the incidents. The manager confirmed that the Community Learning Disability Team are involved with the individual; however,this is an ongoing piece of work . The manager was required as a matter of urgency to seek support and guidance from her line manager and the Community Team with a view to devising interim guidance in relation to “de escalation “ techniques for the individual. This is required to be documented , reviewed and shared with all staff. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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) 12 and 17 Links with the local community are good with appropriate activities being provided based on Service Users interests. Menus were seen to be well balanced ,creative and offering choice but are not accessible to Service Users. EVIDENCE: Service Users are involved in a range of activities which are both community based and “in house “. The Organisation have their own designated staff team responsible for devising daily planners for Service Users activities. These include horse riding, shopping, leisure pursuits, gym membership, swimming and adult education. Files viewed indicated that Service Users interests prior to admission are pursued where appropriate and desired by individuals. One Service User confirmed that they have a daily planner and were aware of what they were doing on the day of inspection. Another Service User was able to indicate what they had planned by signing. The planners were seen to be devised in both a written and pictorial format . Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 13 The Home has their own vehicle which is utilized to support Service Users activities. The Home has a menu which was seen to be displayed in the kitchen. It was varied and changed on a four weekly basis. Service User’s are involved in the planning, purchase and preparation of meals. However, in discussion with one of the Service User’s it was evident that they were unable to read the menu and depended on staff to advise what meals were planned for the day . As there are no Service User’s accommodated who are able to read discussions were held with the manager in relation to the menu being produced in a pictorial format. One Service user indicated that they enjoyed the meals provided. The manager advised that this would be discussed with the Home’s communication’s organiser. Five of the eight staff team had completed food hygiene training. In discussion with one staff member it was evident that they were aware of their responsibilities in ensuring the safe preparation of food . There were ample hand washing facilities in the kitchen . Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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) 19 and 20 The Home is meeting the physical and emotional health needs of Service Users. Systems for monitoring medication administered to Service Users needs to be improved. EVIDENCE: Service User’s have access to a GP and specialist health care services as required of which some evidence was documented in two files viewed. The Home has a medication policy and procedure which is shared with all staff during their induction and, following any amendments made by the management team of the Organisation. Records viewed confirmed that medication administered by staff had been signed for . Medication was seen to be appropriately stored with Service Users having their own individual shelf in the medication cupboard. All staff with the exception of a recently appointed member of the Team have undertaken medication training. There are no Service User’s who self medicate. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 15 There was however one area of improvement that required attention by the manager. This related to care plans including guidance to staff with regards to as to when they administer PRN ( as required) medication to one Service User. For example one staff member advised that the manager had given verbal guidance to the staff team in relation to one Service User who requires medication for anxiety. There was no documentation however to support the guidance given. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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 and 23 The Home has a satisfactory complaints system. Arrangements for protecting Service Users are not satisfactory placing them at possible risk of harm. EVIDENCE: The Home has a complaints policy and procedure which is shared with all staff during their induction and ongoing as required. Staff spoken to confirmed that they were aware of how to contact the Commission and the Organisation’s procedures. The Home have not received any complaints since the last inspection. Service User’s are provided with a pictorial format of the complaints policy and procedure . Due to the various needs of individuals the manager confirmed that relatives/representatives are also provided with a copy. Five of the eight staff have undertaken Adult Protection training and in discussion with one staff member they demonstrated an understanding of their responsibilities. The manager confirmed that she had not received abuse training and had not read the Hampshire Adult Protection policy and procedure. The manager also indicated that there have been a number of incidents where one Service User has attacked other Service User’s in the Home. These incidents should have been discussed with Social Services under the Protection of Vulnerable Adults Policy and Procedure and notification sent to the Commission. All staff have undertaken restraint training (SKIP). The manager confirmed that it is practised on occasions. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 17 However, there were no guidelines as to the approach to be taken or, when restraint should be used in the two files viewed. One staff member confirmed that their instructions were to administer medication when behaviours escalate. Service User’s monies were not inspected on this occasion. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 18 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) No Standards were assessed on this occasion. EVIDENCE: Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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) 35 and 36 Service Users are being supported by a trained and well supported staff team who would benefit from further training. EVIDENCE: Since the last inspection staff have received a range of training which includes fire safety , food hygiene, autism focus and restraint (SKIP). All new staff undertake a thorough induction which is currently being refreshed utilising the Learning Disability Award Framework. The Organisation have their own Training Manager who organises training for the Home in conjunction with the manager. Two staff spoken to confirmed that they receive regular training which is provided on a three weekly basis. One senior member of staff is currently undertaking the Learning Disability Award Framework training. The manager provides regular two monthly supervision and twice yearly appraisals. In discussion with one staff member it was evident that they felt supervision to be very helpful. However, training in some areas of service provision had not been undertaken by all staff. For example there was no evidence that staff had received moving Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 20 and handling training and 3 of the 8 staff had not undertaken food hygiene training or Adult Protection training . Health and safety training had been arranged for July . Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 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) 42 Health and safety needs to be improved in the Home to ensure the safety and welfare of Service Users and staff. EVIDENCE: The manager confirmed that all staff have access to the home’s health and safety policies and procedures which are shared with them during their induction and ongoing as required. The manager further advised that new members of staff would be shown fire procedures during their first shift in the Home. All staff have received fire training with the exception of the manager who was due to undertake the training the next day. Staff spoken to were aware of the fire evacuation procedure but had not undertake one in the Home. The manager advised that she would be undertaking an evacuation to include night staff to ensure staff were familiar with their role and responsibilities in such an event. Cleaning materials were seen to be safely stored. Fire records were up to date . Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 22 However, a risk assessment of the building could not be found although the manager was sure this had been completed by the maintenance team. This needs to be available in the Home and will be followed up at the next inspection. On inspection of the fridge it was evident that food was not being labelled after opening and as a consequence a system was required to be instigated to ensure this was being actioned by staff. Despite a requirement by the Organisation records viewed confirmed that temperatures of hot food served had not been recorded since 17/4/2005 . On inspection of the menus there was evidence that this should have been undertaken on a number of occasions. The manager was required to ensure that a further system was in place to monitor temperature recording of all food served to Service Users as appropriate. Up to date certificates of appliances were not inspected on this occasion. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 Cloverdale Score Standard No Score Version 1.20 Page 23 H54 S11907 Cloverdale V221193 03.05.05.doc 1 2 3 4 5 x x x x x 22 23 ENVIRONMENT 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 2 Standard No 31 32 33 34 35 36 Score x x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 24 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 6 Regulation 17 Requirement The Registered Providers must ensure Service User plans are sufficient in detail to provide clear guidance to staff on the actions to meet their health and welfare needs. Service User plans must be kept under review. Timescale for action 3/6/2005 2. 3. 4. 5. 23 13 The Registered Providers must ensure that all staff receive training in Adult Protection and its application to service delivery. The Registered providers must ensure Service Users are protected from abuse and, that consultation takes place with Social Services under the POVA polic and procedures following an incident of abuse. The Registered Providers must ensure all staff undertake moving and handling and food hygiene training . The Registered Providers must ensure systems are in place for the safe storage of food. H54 S11907 Cloverdale V221193 03.05.05.doc 10/5/2005 6. 23 13 3/5/2005 7. 35 18 3/7/2005 8. 42 23 3/5/2005 Cloverdale Version 1.20 Page 25 9. 10. 11. 23 37 The Registered Providers must ensure the Commission are notified of any event which adversely affects the well being or safety of any Service User. 3/5/2005 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 17 20 Good Practice Recommendations The Registered Providers must produce menus in a format suitable for the Service Users accommodated. The Registered Providers must ensure written guidelines are provided for all staff who adminster as required medication to Service Users. These must be kept under review. Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 26 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Cloverdale H54 S11907 Cloverdale V221193 03.05.05.doc Version 1.20 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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