Inspection on 20/12/07 for Clyde House

This inspection was carried out on 20th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clyde House 26/07/06

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Alfred House Residential Care Home

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Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Clyde House 330 Wellington Road North Heaton Chapel Stockport Cheshire SK4 5DA Lead Inspector Ann Connolly Unannounced Inspection 20 December 2007 13:30 th Clyde House DS0000066601.V350878.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 Clyde House DS0000066601.V350878.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. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clyde House Address 330 Wellington Road North Heaton Chapel Stockport Cheshire SK4 5DA 0161 432 8677 0161 432 8677 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) Clyde House Limited ** Post Vacant *** Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 17 service users to include: * up to 14 service users in the category of MD (Mental Disorder) excluding learning disability or dementia; * up to 3 service users in the category of MD(E) Mental Disorder - over 65 years of age, excluding learning disability or dementia. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th July 2006 2. Date of last inspection Brief Description of the Service: Clyde House is a semi-detached Victorian property, with accommodation situated on three floors. The home is owned by Mrs Nawal, who took ownership of the home on the 21st April 2006. The home is an adapted building. There are nine single bedrooms and four double bedrooms. The care home accommodates up to 17 male residents who are recovering from mental illness. The care home is registered for 14 adults between the ages of 25 and 65 plus three who are over 65. Clyde House is situated near to the junction of Heaton Moor Road and the A6; there are shops close by and a bus stop just outside the home. The home has a statement of purpose and service user guide which were reported to be given to prospective service users when they visit the home to look round. The fees for staying at the home were reported to be between £342 and £370 per week. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 20th December 2007. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager and staff working in the home. Prior to the inspection, questionnaires were sent out to the people who live in the home, asking them to comment on how the home is run and managed, and for their views about how the staff supported them. None of these questionnaires were retuned. Questionnaires were sent to professional who have contact with residents in the home and the feedback and comments from those that were returned are included in this report. Several residents living in the home were spoken to in private during the visit and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well and what they needed to do better. This is one of the ways that we get information from the manager of the service, about how they are meeting outcomes for people using their service. Information that was provided in the (AQAA) for this service, was detailed and comprehensive, and provided evidence of a service that was committed to focusing on positive outcomes for the people who use the service. Since the last inspection visit, which took place on 27th March 2007, the Commission for Social Care Inspection has been informed of one concern regarding safeguarding adults, which involved two residents in the home. There was evidence during this visit that the manager was managing the incident well and that procedures were followed appropriately, and the appropriate professional bodies were fully involved. Over the last 12 months there have been no complaints received by the home, and the Commission has not received any complaints about this service. What the service does well: The residents in this home are supported and encouraged to contribute on how the home is run, and are able to talk or show their concerns and worries and be able to make choices that affect them. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 6 From talking to residents and staff, the service showed that they encourage people to be as involved as possible in areas such as keeping their home and personal space clean and homely. Each resident is supported to keep his room clean. Residents are encouraged to make their own decisions and choices about holidays, social and leisure events. There were examples of residents being supported to attend local classes, and drop in centres. There was good access to medical and health treatment, and residents were supported to keep appointments with healthcare professionals. The home helps residents to maintain their health and wellbeing through supporting them to regularly visit their GP, dentist, optician and specialist health providers. The home has a lot of knowledge and understanding of people’s specific individual health needs and works closely with other healthcare services to monitor and respond to any changes. An example of this was shown when the home noticed a change in a person’s health and quickly got medical help to find out what was going on. Changes were made to the care plan to ensure that all aspects of this resident’s needs were met. Residents who were spoken to said that they were very happy in the home. One resident said, “People are very friendly here. I have a great time with the staff, they go with me to hospital appointments. I get out a lot, and I would go and talk to the staff if I had a worry”. One resident said he was very happy in the home, “Staff treat you well, and you can talk to them about anything”. Feedback from healthcare professionals was very positive. One healthcare professional stated that the service always sought appropriate advice and acted upon it to manage and improve the individual care needs of residents in the home. Feedback also stated that the service always ensured that the general care and supervision was appropriate for the needs of the residents in the home. What has improved since the last inspection? There have been a number of improvements in this service since the last inspection. Mainly, this was as a result of the commitment of the staff team and the manager to meet the requirements from the previous inspection so that residents could benefit from a well-run service. Care plans were much improved so that the needs of residents were clearly identified and provided instructions for staff on how to support residents. All care plan files now include ‘an essential lifestyle plan’, where residents are consulted about their interests and preferences. This will ensure that residents are supported to lead a positive lifestyle. There was evidence that the manager was actively investigating a range of suitable activities and outings for residents. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 7 There was evidence of an ongoing rolling programme of refurbishment and decoration throughout the home. This has been a positive improvement and ensures that residents can benefit from and live in a clean and homely environment. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ needs are assessed prior to admission to the home so the home is sure it can meet the personal needs of individuals in the home, and prospective residents are confident their needs will be met. EVIDENCE: Since the last inspection in March 2007, improvements have been made to the assessment process. In the files that were examined, an assessment was carried out by an appropriate professional and, in addition to this, a member of staff from the home also completed an assessment of needs on any prospective resident. This information was collated and considered by the manager, so that staff in the home could be confident that they had the right skill mix to meet the needs of the individual and so that prospective residents could be confident that it was the right place for them. The manager said that prospective residents were invited to spend time in the home, so that they could make an informed decision about their future care and support arrangements. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 10 Care plan files included a copy of the terms and agreement, so that residents had appropriate information about the facilities and services available in the home, including the key facts of the contract terms. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans provided details of residents’ care needs and the interventions required to meet needs. Appropriate risk assessments are in place to ensure the safety and well being of residents. EVIDENCE: Considerable improvements had been made with the development of care plan files and the process for carrying out risk assessments. Four care plan files were examined during this visit. Overall, care needs were clearly identified, and included the strategies and interventions to meet needs. There was a considerable amount of information on each file about the specific care needs of each individual resident, however, some of this information had not been transferred on to the relevant section of the care plan records. For example, on one file, there was important information in the assessment to help and assist staff to manage some aspects of a resident’s behaviour. Also, some information documented in meetings with psychiatrists, and community psychiatric nurses had not been transferred to the working care plan. It is Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 12 important that this information is available to all staff and easily available for reference, in order to ensure the safety of the resident and the safety and well being of other residents in the home. The manager said that the auditing of all care plan files was an ongoing process. There was evidence during this visit that files were being organised so that staff had easy access to up-to-date information about current care needs. Staff who were spoken to said that this would be a positive improvement, because it would give them a quick reference tool to assist them in supporting residents appropriately and to help them in communicating efficiently with other professionals. Care plans focused on a person centred approach and there was evidence that residents were consulted on how they wanted to be supported. Care plans were supplemented by an essential lifestyle plan, which provided additional information to staff about each resident. Care plans were being developed to include a programme of activity and to provide residents with structure to their day. Care plans included appropriate risk assessments. In one file, there was documentary evidence that risk assessments had been updated to ensure that the staff team managed newly identified risks appropriately. There was evidence that residents were supported to access healthcare services as appropriate. Recordings on files demonstrated that residents were supported to keep appointments with a range of health care professionals, including hospital appointment, regular contact with community psychiatric nurses, and dental and optical appointments. Surveys were sent out to visiting professionals who have contact with the residents. Comments made by these people were positive and stated that the service always sought appropriate advice, and acted upon it to manage and improve the individual care needs of residents in the home. Feedback also stated that the service always ensured that the general care and supervision was appropriate for the needs of the residents in the home. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are supported to engage in activities and maintain social contacts. EVIDENCE: Since the last key inspection of the service, which was in July 2007, and the random inspection in March 2007, there have been ongoing improvements in the way the service supports residents to engage in meaningful activities. All files include ‘an essential lifestyle plan’, where residents are consulted about their interests and preferences. One resident has shown an interest in art and painting, and the manager stated that she has been investigating the possibility of this resident going to an art group. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 14 The information provided by the manager in the Annual Quality Assurance Assessment (AQAA) states that there has been an increase in the outings and activities offered to residents, and that the routines in the home are now more flexible to allow for individual preferences. Residents who were spoken to confirmed that staff supported them and encouraged them to try out different activities, such as college courses and going to local community drop in centres. The service has access to a mini-bus for outings and local trips. The service acknowledged that more improvements were necessary if residents were to experience positive outcome in all aspects of their lives. The information in the AQAA demonstrated that there was an awareness of the importance of extending leisure and social opportunities. The service has identified two key areas for improvement and these include developing a games room in the basement and consideration of providing a computer to help residents to develop new skills. Some activities that had been discussed with residents included membership of a local fitness centre, joining local centres in order to access art classes, shopping trips and a range of ‘in-house’ activities, such as quizzes and entertainers. The comments in professional surveys stated that the service supported individuals to live the life they choose. During this visit, residents were seen coming and going independently. One resident talked about the pleasure he experienced from shopping locally for bargains. Staff were observed engaging in meaningful conversations with residents, asking about their day and what their plans were for the following day. Residents spoke highly of the meals served in the home. There were examples during this visit of a flexible approach to meals. One resident who was hungry was supported to make a snack and residents were seen making cups of tea and having biscuits. A new cook had been appointed and was due to take up her position after Christmas. The manager felt that this would improve the service and provide opportunities to develop the menu, and include residents in menu planning. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported to access health care support services when this is appropriate. EVIDENCE: Records in the home provided evidence that the service supports residents to access health care support services as appropriate. Where it has become necessary to involve other professionals, the service has made appropriate referrals and maintains the necessary documentation and recordings to demonstrate that residents are receiving the correct support. Feedback from professionals involved with the service, confirms that the service always maintains the necessary contact; one person stated, ‘the service contacts the GP for advice and consults regarding adjustment of medication, and involves secondary care support if appropriate’. A medication policy was in place. All staff responsible for the administration of medication have received training and there was evidence during this visit of a rolling programme for training in the safe handling of medication. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 16 Overall, the practice of handling medication in the home was carried out in a manner to ensure the safety and well being of residents. Medication was administered using a monitored dosage system. Medication records (MAR), contained sample signatures of those staff responsible for the administration of medication. On 21st May 2007, there was evidence that medication records and stock levels had been audited by the manager. However, since this date, the task had not been completed. One record showed that a medication had not been reordered, as the General Practitioner had stopped the medication; however, staff had continued to sign the MAR sheet to indicate it was being administered. This shows that staff are not reading and checking the MAR sheets properly. It was strongly recommended that the manager resume the task of carrying out regular audits of medication and assessment of staff competency levels in carrying out this task. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies and systems are in place to support residents in making a complaint when appropriate and to ensure they are protected from abuse. EVIDENCE: There is a clear and accessible complaints procedure in place, which outlines the timescales for dealing with a complaint and informs residents how complaints are dealt with. A complaints book is in place to record comments and issues raised by residents. There are no recent entries in the record and the Commission for Social Care Inspection has not received any complaints about this service since the last inspection. Residents who were spoken to, expressed confidence in approaching the staff with issues of concern. One resident said, “The staff treat you very well, and you can talk to them about anything”. During the course of this site visit, residents were seen approaching staff with issues and concerns, and it was noted that the staff team took time to listen and respond appropriately. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 18 Information provided by the manager in the AQAA provided evidence of a service that was committed to ensuring that residents were fully supported to express their views and to make a complaint. The manager demonstrated an awareness of changes in legislation and said she had received training on the Mental Capacity Act. She stated that the service had plans to use independent Mental Capacity Advocates when this became appropriate, so that each resident was given the opportunity to be fully represented if the situation required it. A number of staff had undertaken training in Safeguarding Adults and staff who were spoken to during this visit were able to demonstrate a good understanding of issues surrounding abuse. Most were aware that Social Services took the lead following an allegation of abuse and that Commission had to be informed. There has been one safeguarding matter reported to the Commission. This incident involves two residents in the home. There was evidence during this visit that the manager was managing the incident well, that procedures were followed appropriately and the appropriate professional bodies were fully involved. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was maintained and decorated to a reasonable standard. The standards of cleanliness and hygiene were good, providing residents with a clean and pleasant place to live. EVIDENCE: Since the last inspection, the home has undergone a programme of ongoing refurbishment and renewal. The information in the AQAA states that all communal areas and bedrooms have been redecorated. The information states that this programme is ongoing and that there are plans to refurbish the shower room. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 20 During the visit, it was evident that a considerable amount of work had been carried out. The lounge areas were fresh and newly painted, and provided residents with a pleasant and relaxing environment. Two residents took pride in showing off their bedrooms and said they were really pleased with their personal space. There was evidence that a number of residents had chosen to personalise their rooms with their own belongings, reflecting their tastes and interests. New bedding and curtains had been purchased and several items of furniture. The manager stated that the programme of maintenance and renewal was ongoing and that they recorded this in a maintenance book. There are two lounges on the ground floor. Due to the high number of residents who smoke, one of the lounges has been designated as a smoking room. The cellar area is due to receive attention and the manager said that research is being carried out on how best to use this area. She said that some consideration is being given to providing a games room. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Robust recruitment and training programmes for staff have been improved and prioritised. Residents using the service can be confident that staff receive appropriate support and training to ensure that they have the right skills to help them to meet the needs of the people they provide care and support to. EVIDENCE: During this site visit, there appeared sufficient staff on duty to meet the needs of residents in the home. Staff were engaged in discussion and activities with residents. A duty roster is in place and details the names of the staff on duty. The cook had recently left and care staff were involved with cooking duties; however, the manager said that extra time had been allocated for this and that a new cook was scheduled to commence employment at the home after the Christmas holiday. Staff who were spoken to said that they were managing this arrangement well in the interim period. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 22 Since the last site visit, the programme of staff supervision had improved. The staff team who were spoken to confirmed that they were in receipt of regular supervision. Staff also said that they had access to training and development opportunities. One member of staff said, “Since the new manager came into post, things here have improved in every aspect. There is a chart to check when people have had supervision and we have had training on the Mental Capacity Act”. Another member of staff said, “There’s been a big improvement to the building and the running of the place. I have regular supervision and have had training in Adult Protection and first aid. I feel the staff meet the needs of residents, we support residents to go out and get involved in activities. Information provided by the manager in the AQAA stated that 70 of staff were trained to NVQ level 2 or above. All new staff receive induction training. The manager was in the process of developing training files for each member of staff to assist her in monitoring training needs of the staff team. A selection of staff files were examined and provided evidence that policies and procedures for the recruitment of staff had been followed. In the staff files examined, there was an employment check, two written references and Criminal Record Bureau checks. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 44 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies and procedures are in place to ensure that the safety and well being of residents are protected. EVIDENCE: There is a manager in post who has made a positive contribution to the running of the home in the short time she has been working there. The staff team said that things had improved in the home and that the manager was very approachable. It is the intention of the manager to submit an application to become the registered manager of the service. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 24 There was evidence during this visit that the manager and the staff team were working hard to meet the requirements made at the last inspection and to continue to improve and develop the service. Most requirements from the previous inspection had been addressed or were in the process of being met. Information in the AQAA states that policies and procedures have recently been updated and the manager said that this included fire procedures and checks. The home had a policy and procedure for supporting people with their personal finances. Financial transactions were recorded and the resident and staff member sign the record. Receipts for purchases are maintained on file. The requirement made at the last visit, to notify the Commission of any incident which affects the well being of residents, has been addressed. The manager had notified the Commission appropriately of a safeguarding issue, and was seen to be handling this incident appropriately. Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 25 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 X 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 3 X Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 26 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 YA37 Regulation 8, 9, 10 Requirement The manager must make an application to be registered with the CSCI. (Timescale of 30/04/07 not met). Timescale for action 10/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Care plans need to be regularly reviewed, so that current care needs are added and included in the care plan. This will ensure that care needs are not overlooked and that staff have the correct, up to date information to help them to support residents appropriately. It was strongly recommended that the manager resume the task of carrying out regular audits of medication and assessment of staff competency levels in carrying out this task, so that residents can be confident that they are supported appropriately to receive their medication safely. 2 YA20 Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Clyde House DS0000066601.V350878.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!