Inspection on 21/11/07 for Cloverdale Care Home

This inspection was carried out on 21st November 2007.

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

Cloverdale Care Home 20/10/08

Cloverdale Care Home 17/08/06

Cloverdale Care Home 03/03/06

Cloverdale Care Home 21/10/05

Cloverdale Care Home 20/01/05

Cloverdale Care Home 13/07/04

Cloverdale Care Home 06/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Cloverdale Care Home 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH Lead Inspector A Eileen Engelmann Key Unannounced Inspection 21st November 2007 09:30 X10015.doc Version 1.40 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 Care Home DS0000002780.V355263.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 Older People. 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 Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloverdale Care Home Address 68 Butt Lane Laceby Grimsby North East Lincs DN37 7AH 01472 877000 01472 877010 surinder.khurana@ntlworld.com 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) Dryband One Ltd Position Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (40) of places Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2006 Brief Description of the Service: Cloverdale Care Home is registered for the care of forty people with residential care needs. The home is situated on the outskirts of Laceby village, in North East Lincolnshire, about six miles south of the town of Grimsby. The home is purpose built, with accommodation being provided at ground level. All forty bedrooms are single and thirty-nine have en-suite facilities. The home has four bathrooms with toilets and an assisted shower room. There are also four single toilets throughout the home strategically placed for ease of access. The home has two lounges and a dining room; since the no-smoking regulations came into force in July 2007 the home provides people with a specific smoking area. Cloverdale Care Home is set in its own grounds and enjoys a pleasant aspect of open countryside. A paved walkway surrounds the home and there are ample parking spaces to the front of the building. The home is well maintained, clean and has a homely feel. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is also available from the manager. Information given by the manager on 21/11/07 indicates the home charges a fee of £345.00 per week and that there are no additional charges other that those for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. A full list of prices for these additional services is available from the manager. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information has been gathered from a number of different sources over the past 12 months since the last key visit in August 2006, this has been analysed and used with information from this visit to reach the outcomes of this report. Since the last key visit in August 2006 the registered manager of Cloverdale has left and a new person has been appointed to this role. She is not registered with the Commission for Social Care Inspection, but for the purposes of this report she will be referred to as the manager throughout the text. This unannounced visit was carried out with the manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home, staff and healthcare professionals inputting to people’s care. Their written response to these was good. We received 8 back from relatives (73 ), 5 from staff (45 ), 1 from a healthcare professional (20 ) and 6 from people using the service (60 ). Three safeguarding of adults allegations have been made since the last inspection in August 2006. The safeguarding of adults team at the local social services have investigated and resolved two allegations and the third investigation is still ongoing at the time of this visit. What the service does well: All of the people living in the home were positive about the home and like living there. Three people said they loved living at the home and the care was very good. People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The person who owns the home must make the statement of purpose and service user guide better by putting more information into it. People living in the home said that the staff are very good at talking to them and they felt comfortable talking about the service and their needs. People working in the home must make sure the information in the care plans shows the life history of those coming into the home, so activities and the care to be given reflects the needs, interests and likes or dislikes of each person using the service. The people working in the home should be talking to the residents more to find out what they like and how they want to be looked after. This helps the residents to have choice in how they are cared for and helps them stay as independent as possible. People in the home who have dementia or sensory disabilities must be given a better choice of social activities to keep them happy and able to join in with others. People who are working in the home have to be given training around keeping people safe from harm, this helps them understand how to look after individuals and speak up if they think anything is wrong. People who are working in the home have to attend more training around safe working practices to make sure they look after their health and safety and that of the people living in the home. The person who owns the home must make sure that the service is looked at on a regular basis to see if it is meeting the needs of the people using it, is working within the guidelines of good practice and is looking after the wellbeing of the people living in the home and the people who work there. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 7 We would like to thank everyone who completed a questionnaire and/or took the time to talk to us during this visit. Your comments and input have been a valuable source of information, which has helped create this report. 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. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes needs assessment process is inadequate and does not give individuals full written assurance that their needs can be met, prior to their coming into the home. EVIDENCE: The majority of people who completed a survey said they received sufficient information to make an informed choice about the service before coming into the home. One individual said ‘all the staff are good with communication, if I have any queries they are ready to listen and try to help me’. The statement of purpose and service user guide requires updated information in them to show the current management arrangements and the correct contact details for the Commission for Social Care Inspection. The service user guide also requires information about fee prices and the cost of additional services. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 10 At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that assessments and care plans completed by care management are obtained by the home and people or their representatives receive formal confirmation that, having regard for the assessment, their needs can be met in the home’. Checks at this visit show that the requirement is not fully met and so it will remain on this report. Four people’s care and records were looked at in depth during this visit and all of these individuals had been assessed by the manager before they came into the home or this was done on the day of admission. Only one of the four people had a social service assessment or care plan in their files and the one seen was faxed to the home on the day of admission. The manager must make sure she obtains a copy of the care management assessment or carries one out before offering a placement to an individual. This will help her fully understand the person’s needs and expectations before they come into the home and enable the home to have any equipment or healthcare professional input in place before they are admitted. Discussion with the manager indicated there is a formal, written process of offering placements to people who are interested in using the service. This is not used all the time and it was recommended that the manager become more consistent in using this approach, as a matter of good practice. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of their specific problems/abilities and the care given on a daily basis. Discussion with people showed that they were satisfied with the care they receive and have a good relationship with the staff. Comments from the surveys said ‘I am satisfied with the care my relative receives,’ and ‘staff are very understanding and competent’. The home has an equal opportunities policy, which is used when employing staff. The staff group are mainly White/British although people from overseas are employed if they have acceptable skills and qualifications. People using the service are unable to make a choice of staff gender when deciding whom they would like to deliver their care, as the home has no male care staff due to a lack of suitable applicants. The manager said that she would discuss this with people wanting to use the service during the assessment process. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that the majority of people are of white/British nationality. The home does accept residents with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 11 Information from the training files and training matrix indicates that not all the staff are up to date with their basic mandatory safe working practice training, or have accessed a range of more specialised subjects that link to the needs of people using the service. A number of people using the service have dementia needs and some of the staff have undergone a one-day training course in dementia, but only three have done this in the last two years. This may not be sufficient training to give the staff a good, clear understanding of dementia, what the different types of dementia are, how they affect people and how they can help people with dementia’. Discussion with the manager indicated she is aware of the need to develop the training programme further and that individuals are being booked onto courses as they come available. The responsible individual must make sure that staff have the skills and knowledge to deliver the services and care which the home offers to provide. This will help to develop a consistently high standard of care, which maintains and promotes the people’s health, safety and wellbeing. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not person centred and do not ensure that people’s wishes and choices regarding their care are recorded and met. However, personal support in this home is offered in such a way as to promote and protect people’s privacy, dignity and respect. EVIDENCE: At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that care plans have clear tasks for staff in how to maintain service users independent skills and changes highlighted in evaluations are followed through to the care plans’. Checks at this visit indicate that this has been met. The care of four people was looked at in depth during this visit and included checking of their personal care plans. The content of the plans is very task orientated, and does not explore fully the personal wishes or needs of the people living in the home. The plans would benefit from additional information Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 13 about the individuals abilities, strengths, weaknesses, personal preferences, likes and dislikes. Some effort has been made to ensure that a life history of each individual is in place, but a number of these were not detailed enough to give a picture of the person at the centre of the plan. Care plans are being evaluated monthly, but staff must make sure they are signing each time they record in the plans. The care plans contain very little information about the wishes and choices of individuals regarding their spiritual needs, their decisions regarding palliative care or action to be taken in the event of death. Not all people are receiving a review of their care plan on a yearly basis with the funding authority, family or representative. These issues were discussed with the manager and the homes operations manager who assured us that action would be taken to improve the care plans. Information from the surveys indicates that the majority of people who responded are satisfied that the staff give appropriate support and care to those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. One person said ‘I am happy and well care for in the home, staff are nice to me and I get on well with them all’. Two other people commented that ‘sometimes the staff are very busy, but they always respond quickly if we ring our bells’. At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that risk assessments are completed for the two service users at risk of falls, risk assessments for bedrails are updated when needs change or the plan becomes ineffective’. Checks at this visit showed this has been partly met and a requirement around risk management will remain on this report. Checks of bed rails etc were not available at the time of this visit (see standard 38), although bed rail assessments were in the care plans were needed. The manager should make sure that risk management plans/assessments are discussed with the individual or their representative and signed in all cases. Two people said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. People have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Responses to the surveys indicated that people and their relatives are satisfied with the level of medical support given to the people living at the home. The health care professional who completed the survey said ‘staff are very good at supporting people to administer their own insulin. They work well with people who are depressed and ensure they participate in daily life within the home. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 14 Checks of the medication show the home is using the NOMAD cassette system of medication. Observation of the medication records show the records are up to date and well managed. Checks of the controlled drugs and register showed that these medicines are monitored carefully, stored correctly and records are accurate. Two areas were staff practice could improve are • Where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. • Stocks of medication held in the home, which are given on an as and when needed basis (PRN), should be brought forward onto each new MAR chart so an accurate audit can be carried out. People and relative comments show they are very satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with choice and diversity in the activities and meals provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that the activities provided suit the range of needs experienced by the service users’. Checks at this visit show that this has been partly met, and will remain as a recommendation in this report. The manager has made definite attempts to introduce a better range of events and activities for the people in the home, but there is a need for more 1:1 interaction with those less able to join in with group events. Daily activities included bingo, board games, cards or dominoes and an outside entertainer is booked at least once a month. Discussion with the manager indicated she is looking at introducing occupational therapy and reminiscence sessions within Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 16 the home to offer people with dementia or sensory disabilities more opportunities to participate in stimulating pastimes. People and relatives told us that ‘people are given the freedom to have their own life within the constraints of the care home environment’, ‘staff understand when you want to spend time alone’. Three people said ‘I join in with bingo and singing, but not all the time. I like to watch my television and DVD player in my room’. ‘There are lots of activities and I take part in the ones I want to go to’ and ‘I like the musical acts. I am encouraged to join in with other things like bingo, but prefer to be in my own room listening to my music’. One person told us that ‘I keep myself busy with cross-stitch, puzzles and crosswords. Five people attend the British Legion and WRVS club on a Wednesday, two people attend the Friday Club and some individuals go to the Stroke Club on a Monday. The home has regular visits from the Council’s Mobile Library Service and there is a selection of videos that people can choose from and watch in the lounges or their own rooms. Information from peoples’ files indicates that there are a number of individuals who follow different spiritual faiths, including Catholic and Church of England. The manager said that there are regular church visitors (monthly) within the home and people could go to the local church services and religious celebrations as requested. The home provides special meals and cakes for birthdays and helps people celebrate all major Christian festivals such as Easter, Harvest Festival and Christmas. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the community. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Relatives and visitors to the home are very positive about the service and the staff. Written and verbal comments given to us showed a high level of satisfaction. One person said ‘the home is welcoming and the staff are caring, helpful and efficient’. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. There are meetings where the viewpoints and opinions of those living in the home can be expressed and the management team will listen and take action were needed. Visitors said they are kept informed of any important issues affecting their friend/relative and felt that staff did a good job of supporting people to live the lives they choose. There is a range of information and advice on different matters including, advocacy and individual’s rights. This is on display in the entrance hall. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 17 At the last visit in August 2006 a requirement was made that ‘The registered manager must seek service users views on the timing of the evening meal and supper provisions and ensure that there is less than a twelve hour gap between the provision of supper and breakfast the next morning. Individual needs to be accommodated as far as practicable’. Checks at this visit found that this has been met. Comments from the people living in the home and their relatives are on the whole very positive about the meals and kitchen service provided. Individuals commented that ‘the food is excellent’, ‘the cooks are nice and friendly’ and ‘I have a problem eating, but the home have done all they can to help me’. The lunchtime meal was well presented and offered a good choice of food, menus were available and the dining room was welcoming and spacious. Staff were organised when serving the meal and a number of individuals were seen to offer assistance to people who needed help with eating and drinking. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a good complaints system with some evidence that peoples’ views are listened to and acted upon. Visitors and people using the service are confident about reporting any concerns and the manager acts quickly on any issues raised. The uptake of staff training in safe guarding of adults is unsatisfactory and does not ensure people using the service are protected and kept safe at all times. EVIDENCE: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and all of the survey responses from people using the service showed individuals have a clear understanding about how to make their views and opinions heard. Those people spoken to said ‘we would talk to the staff or the manager if we had any problems’. Relatives who completed a survey said that they felt the home responded appropriately if they raised a concern and minor issues were dealt with quickly. One relative said ‘staff have supplied us with forms if needed’. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 19 The Commission for Social Care Inspection has received one formal complaint since the last visit in August 2006, this was given to the provider to investigate and was resolved with no further action needed. Three safeguarding of adults allegations (abuse) have been made since the last visit in August 2006. The home has taken appropriate action to report any incidents and has worked with the Social Service team who investigates the allegations. Allegation one was regarding physical abuse; this was investigated by the team and not proven. No further action was required by the home. Allegation two was regarding financial abuse. The police and the team investigated this and did not take any further action. The home has fitted door locks to two people’s bedrooms at the request of the people living there. Allegation three is regarding physical abuse. The team are still investigating this. At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that all staff including ancillary staff receive training in the protection of vulnerable adults from abuse’. Checks at this visit indicate that this has not been met and will remain as a requirement on this report. Information from the staff training matrix indicates that Safeguarding of Adults training is ongoing, two people have completed this since the August 2006 visit and thirteen are booked onto courses within the next four months. The provider must also consider the need to offer staff training in management of challenging behaviour and dementia care to ensure the needs of all people using the service are recognised and met. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers a safe, comfortable and clean environment for those living there and visiting. EVIDENCE: The home was purpose built twelve years ago and offers accommodation to people on the ground floor and office space on the first floor. The corridors in the home are wide and have handrails in place, but paintwork in the corridors needs touching up where damage from equipment and wheelchairs has affected the skirting boards and doors. The operations manager told us that the home plans to have plastic skirting boards fitted. The home is in the process of building a conservatory and this will be accessed from the double doors in the lounge area. This work should be completed by Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 21 December 2007, with the decoration and refurbishment finished by January 2008. Information from the manager and operations manager is that corridor carpets are going to be replaced and new flooring is planned for the dining room. The dining room furniture is looking worn and should be considered for replacement. There is a hole in the dining room wall next to the fire extinguisher and one behind the door leading onto the kitchen corridor. Both holes need to be repaired. The flooring in the corridor leading to the kitchen is planned for renewal and will be replaced with a vinyl floor covering to improve the appearance and cleanliness of the area. The outside seating areas are let down by the old and broken furniture and a lack of interesting features for people to see whilst sat out in better weather. There is a planned maintenance programme for redecoration and refurbishment within the home and a copy of this was given to us at this visit. The timescales on the programme indicate that all work will be done by April 2008 at the latest. At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that the odour in one of the bedrooms is investigated and eliminated and the melamine teapots cleaned or replaced’. Checks at this visit found this to be partly met, and a requirement around odour control will remain on this report. Some odours were noted throughout the home during this visit. Discussion with the operations manager indicated that the home is considering replacing some bedroom carpets with a more hygienic floor covering that will help to eliminate odours and be infection control effective. Comments from the surveys indicate that people are very satisfied with the laundry service within the home. One individual said ‘ the laundry is excellent, it is well run and efficient’. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff do not have access to sufficient training and development sessions to ensure they have the skills and knowledge to meet the needs of the people living in the home. Failure to improve training may result in the health, safety and wellbeing of people being put at risk. EVIDENCE: At the last visit in August 2006 a requirement was made that ‘The registered person must ensure the correct staffing hours are provided to meet service users needs. It is recognised that newly recruited staff, about to start induction, may resolve the issue’. Checks at this visit found this has been met. At the last visit in August 2006 a recommendation was made that ‘The registered manager should calculate dependency levels of service users and hence the required staffing hours by using an appropriate tool’. Discussion with the operations manager at this visit indicates this has been met. At the time of this visit there were 29 people living in the home and the rotas showed that staffing was as follows – Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 23 7am to 2.15 pm – four care staff 2.15 pm to 9.30pm – four care staff 9.30pm to 7am – three care staff Information from the annual quality assurance assessment and staff rotas about the number of staffing hours provided, and information gathered during this visit about the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. These figures do not include the manager’s hours or those for domestic and cleaning activities. Comments from the staff, relatives and people using the service indicate that the home is extremely busy at times, but people feel that there is a good standard of care being given to the people living in the home. Survey responses said ‘the staff are kind, caring and help support relatives as well as the people using the service’. A recommendation from the last visit in August 2006 was that ‘The home should continue to work towards 50 of staff trained to NVQ Level 2’. Checks at this visit indicate this has been met. There is an induction and foundation course that meets Skills for Care specification for new members of staff, and information from the staffing matrix indicates that 47 of staff have achieved an NVQ 2 with one person waiting for their certificate and three more waiting to start the training. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that two written references are consistently obtained prior to employment’. Checks of four staff files indicated that this is now met. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police/Criminal Records Bureau checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. At the last visit in August 2006 a recommendation was made that ‘The registered person should ensure that staff receive three paid training days per year’. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 24 Discussion with the manager indicated all staff are paid for three days training a year, however checks of the staffing matrix indicates not all staff are taking this up. This recommendation will remain on this report. The home provides a mandatory staff-training programme that links to training provided by the company and other outside agencies offering free cost packages. Information from the staff training files and training matrix indicates that the majority of the staff are up to date with their basic moving and handling safe working practice training, but a high number need to attend training and/or updates on fire, health and safety, infection control, safeguarding of adults and food hygiene. There is evidence that the home has thought about introducing more specialist training looking at conditions linked to old age and dementia, but uptake of these courses is slow due to staff being unable to attend because of needing to cover the care shifts, and within the Training Facilities places on the courses are limited and date specific. The manager is aware of the need to improve the training and has booked staff on a number of courses over the next four months, but they depend on places being available. The responsible individual must ensure the staff receive basic mandatory training and more specialised training that reflects the different care needs of the people living in Cloverdale. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems for quality assurance and risk assessment within the home are not robust and must be improved to ensure the health, safety and welfare of the people who live in the home and staff are maintained and protected. EVIDENCE: The acting manager has been in post since August 2007. This person has been working in the care industry for 10 years, working her way up from a care worker to the management position she is in today. The acting manager is hoping to start her Registered Managers Award next year and put in for registration with the Commission for Social Care Inspection by the end of May 2008. At the moment the acting manager is being supported by her Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 26 operations manager who visits the home weekly and also by the provider who is in regular contact with the home. The home does not have a recognised Quality assurance system in place within the home and discussion with the manager indicated that audits and quality checks are something that she is not familiar with. Checks of the records showed that formal quality audits are not in place and discussion with the operations manager indicates that this is something he is hoping to introduce within the next few months. The provider has improved the standard of policies and procedures within the home and these have been introduced into the service in recent weeks. The operations manager told us that once these have been put into practice then the home would be ready to apply for Investors in People status. The registered provider is completing monthly visits to the home and recording these on Regulation 26 reports, which are available in the home for inspection by the appropriate authorities. Staff and resident meetings are taking place and offer individuals an opportunity to voice their opinions and ideas about the service. Satisfaction surveys are going out to people using the service and their representatives, and the feedback and action taken is recorded by the service on an Annual Development Plan. Checks of the financial records showed that people are able to have personal allowance accounts in the home. These records are hand written and detail the transactions undertaken and the money held for each person, the manager updates these each week. Information from the manager indicates that the majority of people have a family member or representative who looks after their monies and these individuals make sure the personal allowances are sent/brought into the home. Four accounts were checked and found to be up to date and accurate at this visit. At the last visit in August 2006 a requirement was made that ‘The registered person must ensure that all care staff members are on track to receive at least six formal supervision sessions per year’. Checks at this visit found that the manager is beginning to carry these out, but the short time she has been in post makes it difficult to give an accurate analysis of the process. The requirement will remain on this report until the next visit when the standard will be looked at again. At the last visit in August 2006 a requirement was made that The registered manager must be proactive in monitoring health and safety issues within the home such as risk assessments, bed rails and protectors’. Checks at this visit found that the manager is not familiar with the paperwork involved in ensuring these assessments are completed and indeed could not produce a number of records. The requirement will remain on this report. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 27 At the time of this visit we asked to see water temperature checks, bed rail checks, generic risk assessments for the home, the fire risk assessment, accident books and the maintenance certificates for the home. After some searching the manager provided us with the accident books and maintenance certificates, fire records and water temperature checks. The fire risk assessment was found to be years out of date and no generic risk assessments or bed rail assessments were found. The operations manager assured us that he would provide an up to date fire risk assessment within a week of this visit (this has since been received by the Commission for Social Care Inspection). The operations manager also said that he would be providing the manager with appropriate training so she could complete the generic risk assessments. The maintenance man completes the bed rail assessments and it is recommended that we be sent a copy of these when the Provider receives this report. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes. 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 OP1 Regulation 4, 5 Schedule 1 Requirement Timescale for action 01/02/08 2. OP1 5(b)(c) Amended regulations 2006 The registered provider must produce and make available to people an up to date statement of purpose and service user guide. So people receive enough information about the service and facilities to know if the home can meet their needs, before they decide to accept a placement. 01/02/08 The registered provider must ensure the homes service user guide meets the criteria of Regulation 5 of the Care Home Regulations and includes the information asked for in The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2006 (for Regulation 5), which came into force on 1st September 2006. This is so people know how much they have to pay for their care, what they are getting for their money and the cost of any additional extra services they may wish to purchase. DS0000002780.V355263.R01.S.doc Version 5.2 Cloverdale Care Home Page 30 3. OP3 14 The registered person must 01/02/08 ensure that assessments and care plans completed by care management are obtained by the home prior to a person’s admission; and the people using the service or their representatives receive formal confirmation that, having regard for the assessment, their needs can be met in the home. This is so the home can make sure they have the right equipment, staff skills and expertise to meet the persons expectations and provide the care the individual requires before an offer of placement is given. And people can be assured their needs can be met by the service before committing themselves to placement within the home. (Given timescale of 30/09/06 was not met.) The responsible individual must make sure that staff, individually and collectively, have the skills and experience to deliver the services and care which the home offers to provide. 4. OP4 12(1) 01/04/08 5. OP7 15 So people can be confident that their needs relating to old age and dementia are recognised and managed appropriately. 01/04/08 The registered provider must make sure that the care plans are detailed and individual to the person they are about, putting the person at the centre of it, and giving a picture of who they are as well as what their needs are and how to met them. The plans should meet relevant clinical guidelines produced by professional bodies concerned DS0000002780.V355263.R01.S.doc Version 5.2 Page 31 Cloverdale Care Home with the care of older people and those with dementia. This will make sure that staff have access to information that will help them to provide person centred care and support. The responsible individual must make sure that the staff attend appropriate training in Safeguarding of Adults procedures, management of challenging behaviour and dementia care. To prevent residents from being harmed or suffering abuse or being placed at risk of harm or abuse. The responsible person must make sure that all repairs and renewals as highlighted in this report are carried out. This will enable people using the service to live in a safe and wellmaintained environment, which meets their needs and the outcomes of the statement of purpose. The responsible individual must make sure the premises are kept fee from offensive odours and systems are in place to control the spread of infection. So people living in the home can enjoy their environment and be assured that their health and safety is maintained. The responsible individual must ensure that there is a training programme in place that ensures staff fulfil the aims of the home and meet the changing needs of the people using the service. Specialist training on the elderly and diseases relating to old age DS0000002780.V355263.R01.S.doc 6. OP18 13 01/04/08 7. OP19 23(1)(2) (a) 01/04/08 8. OP26 16(2)(k) 01/02/08 9. OP30 OP38 18(1)(a) (c) 01/04/08 Cloverdale Care Home Version 5.2 Page 32 and dementia must be included in the training programme. So the health, safety and welfare of the people in the home is protected and promoted, and staff have the skills and knowledge to provide a high standard of care. The responsible individual must 01/04/08 make sure that effective quality assurance and quality monitoring systems are in place, which seek the views of people and measure the success in meeting the aims and objectives and statement of purpose of the home. So the home can demonstrate that it is offering a quality service and value for money to the people using the service, and is listening to their views and opinions and taking action to meet its aims and objectives and produce favourable outcomes for people. The registered person must ensure that all care staff members are on track to receive at least six formal supervision sessions per year. (Previous timescale of 30/04/06 and 31/12/06 not met) So staff can receive feedback and support around their work practices and career development needs, and people using the service receive care from competent and experienced people who understand their roles and responsibilities. The registered manager must be proactive in monitoring health and safety issues within the home such as fire risk assessments, generic risk DS0000002780.V355263.R01.S.doc 10. OP33 24 (1)(a)(b), (2)(3) 10. OP36 18(2) 01/04/08 11. OP38 13 01/01/08 Cloverdale Care Home Version 5.2 Page 33 assessments and bed rail risk assessments. This will ensure the health, safety and wellbeing of people living or working within the home is protected and maintained. Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 34 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. 3. Refer to Standard OP3 OP7 OP7 Good Practice Recommendations The manager should make sure that prospective people receive a formal written offer of placement, in line with the homes policies and procedures. The manager should make sure staff sign the care plans each time they evaluate a person’s care. The manager should make sure that all people receive a yearly review of their care by the funding authority (were applicable), and include their family or representative (with the persons consent). The manager should make sure that all risk management plans/assessments are discussed with the person or their representative and signed consent to these is obtained. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), there are two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The manager should make sure that stocks of medication held in the home, which are given on an as and when needed basis (PRN), are brought forward onto each new MAR chart so an accurate audit can be carried out. The registered person should ensure that the activities provided suit the range of needs experienced by the people using the service. The registered person should ensure that staff receive three paid training days per year. The registered provider should make sure there is a registered manager in post by the end of May 2008. The manager of the home should have achieved her Registered Managers Award by the end of December 2008. The registered provider should send the Commission for Social Care Inspection a copy of the bedrail risk assessments on receipt of this report. 4. 5. OP7 OP9 6. OP9 7. 8. 9. 10. 11. OP12 OP30 OP31 OP31 OP38 Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Cloverdale Care Home DS0000002780.V355263.R01.S.doc Version 5.2 Page 36 - 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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