Inspection on 26/07/06 for Clyde House

This inspection was carried out on 26th July 2006.

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 no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clyde House 20/12/07

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

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Fernhaven

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 Kath Oldham Unannounced Inspection 26th July 2006 07:45 Clyde House DS0000066601.V305691.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.V305691.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.V305691.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 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.V305691.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. 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 ownership of Clyde House has changed since the last inspection. The home was purchased on 21st April 2006 by Mrs Mary Nawal. Mrs Nawal has also purchased Heaton Lodge, which is a few yards away from Clyde House. 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.V305691.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key unannounced inspection since Mrs Nawal purchased the home. The inspection took place on Wednesday, 26th July 2006, commencing at 7:45am and was concluded on Monday, 31st July 2006. Mrs Nawal purchased the home on 21st April 2006 and her time has been spent supporting staff in their development and empowering service users. In addition to developing the service provided to service users, Mrs Nawal has undertaken extensive advertising to recruit a manager to the home and an acting manager had been appointed on 24th July 2006. The manager is currently spending time getting to know service users, staff and the building and has identified areas where the home needs to develop to improve the quality of life and service provided to service users. It is his intention to prioritise what needs to be done and devise an action plan to assist in this development. The registered person and manager are working closely together to develop the service that the home provides. This includes staffing, the environment and the type and level of care and support service users receive. This development will take time and priorities have and will be identified in the short, medium and long term. A deputy manager, who has experience of working with service users with mental health needs, has also been appointed to support the development of the home. Time was spent with the registered person, examining records and in observations and conversations with staff and service users. A partial inspection of the building was also undertaken. Comment cards were given out for staff and service users. Comments received are included in this report. There were 15 service users accommodated at the home on the key inspection. What the service does well: The home is able to provide accommodation to 17 service users with mental health needs the majority of which are between the ages of 25 and 65. Several service users told the inspector that they liked living at the home and that they felt cared for. One service user said that living at Clyde House was like living in ‘one big family’. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 6 There have been no complaints about the home since the last inspection. What has improved since the last inspection? The purchase of the home by Mrs Nawal has assisted in the development of the service. Service users have had a residents’ meeting and their views and opinions have been listened to. The meetings have also served the purpose of letting service users know the rules and regulations about living at the home and what they are able to do. Additional meetings are to take place on a regular basis to keep service users informed about the planned changes at the home and to empower them to have a say in what happens. The registered person has spent time with staff and has covered shifts in the home to assist in her own development and to support staff in their role. Service users were positive about the change in ownership. One service user had asked for an organ and this has been provided by the home. Service users were seen to be asked about getting new clothes and shoes and encouraged to take a pride in their appearance. Service users were prompted to dress appropriately and encouraged to be part of the community. The menus have been devised with the involvement of service users. Service users were observed being asked by the registered person what they wanted on the menu for the following week. The registered person has ideas for developing and delivering the service within the home. Continence issues, identified as being difficult to manage, have improved, with service users being guided on what is acceptable practice for both themselves and other service users at the home. Advertisements are to be made locally to obtain new staff to ensure there are enough staff on duty of the quality that is required within a home that cares for service users with mental health needs. Service users have an individual record of their personal allowance, which is signed for by them on receipt. This promotes their dignity and privacy. The gardens at the back of the house have received attention and trees have been pruned or taken down. The rear garden looked well presented with plants and trees providing some interest to service users. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 7 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. Clyde House DS0000066601.V305691.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.V305691.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome area is adequate. Prospective service users are able to visit the home before making any decisions about their future. Written information needs to be developed so service users have all the information they need to safeguard them. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The statement of purpose and service user guide have been developed and although need some slight amendment, are in line with regulations. Service users have not yet received a copy of the revised service user guide, which will provide them with the necessary information about the home and the services they will need. There have been no new admissions to the home since the new ownership. The acting manager stated that they didn’t have a revised assessment format but this would be in place before any new service users were considered for admission to the home and he would undertake an assessment of the service user when referrals are received. The home is to ensure relevant information is known by the home to enable them to provide the correct care to service users. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 10 Assessments from health care or social care professionals will be obtained before the home’s assessment process is commenced. Service users and/or their relatives were given the opportunity to visit the home before making the decision to move in for the trial period. The home is to check which service users have contracts or terms and conditions of residency with the home and ensure these are on file, updated and individualised with all involved in the care placement. Clyde House DS0000066601.V305691.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor. Care plans and risk assessments failed to record all care needs, which has the potential for needs not to be met. This judgement has been made using available evidence, including a visit to this service EVIDENCE: The registered person has not yet developed care plans and risk assessments. Examination of care files identified the care plan process needs to be developed to include the service user’s mental health needs, how these are managed and what indicators are in place to identify when a service user’s mental health needs are deteriorating. Risks are not recorded so a judgement cannot be made whether service users are supported to take risks as part of their independent lifestyle. There is not sufficient detail recorded within the care files. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 12 Contact sheets are in place and provide some information on how service users spend their day and indicate some staff interventions. Service users are able to state their views and opinions on a daily basis. Some service users wait for specific staff to be on duty to tell them their problems or concerns. A service users’ meeting had been arranged at the home, which provided an opportunity for service users to comment on the quality of service provided. These are to be held on a more regular basis so service users have some influence on the service that is provided. There is, for some service users, no structure to their day, the majority of their time being spent drinking alcohol or tea and sitting about. Other service users organise their own lives by visiting shops or relatives. It was reported that additional recreational or educational activities are to be explored to give service users further opportunities in daily living. Service users had access to GP support, district nursing services, social work support, chiropody and community psychiatric nursing services when required. Psychology services were accessed via the GP if required. Clyde House DS0000066601.V305691.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. Service users are not given much opportunity to take part in purposeful activity. The menus need some development to include a choice of meal. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users are supported in using public transport to access facilities in the town centre. Not many of the service users use this opportunity routinely, choosing to sit in the home for the most part of their day. Service users are able to use communal areas of the home freely and are able to use their bedrooms at any time they want. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 14 Most of the service users at the home lack motivation or interest in developing skills to take part in regular activity or take up or develop employment skills. It was reported that, for one service user, work has been undertaken to develop and rekindle skills to go out of the home. This development is in its early stages but has improved the quality of life for the service user. Additional interventions were reported to again further enhance the quality of life for service users. The service has knowledge of what activities and facilities are available within the area and are going to further develop the links to help service users find out about establishing more structure to their day. A handful of service users do take part in some activity or visit shops independently or go to relatives. A number of service users have been at the home for many years and have become institutionalised in their behaviour and attitude, preferring to sit in all day drinking tea, smoking and consuming alcohol. Should a service user express an interest in employment or further education, staff would assist. Currently, service users have not expressed any interests and so need to be motivated and encouraged by staff. There are no service users in employment. Opportunities are provided for service users to attend day centres, take part in hobbies and activities and visit places of interest. However, this is limited to only a few service users. This needs to be addressed in a more proactive way to assist service users to become more involved in the local community. Restrictions would be placed on visitors where it is evident that visitors are not acting in the best interest of the service user. This information is not included in the service user guide and contracts of residence. The introduction of service user meetings and the development of the service user guide and service user contracts should address these areas of development. Service users were observed being asked what they would like to eat for particular meals to assist in the development of a menu. A service user said it was their birthday during the week after the inspection when he was having a party and was able to choose what the menu was for the meal. Service users who commented about the meals said they were “alright”. Other service users said they “liked the meals” and “you get plenty of food”. The menus seen did not detail a choice at the mealtime. A record of food served was not maintained so it was not possible to see whether service users had a nutritional diet. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 15 Care staff are preparing and cooking meals, which takes them away from supporting service users. A member of the care team has been appointed as cook and was to take up that position after the inspection. Advertisements will continue to be placed in an effort to cover the shortfall in cooking hours. Three staff have obtained food hygiene training; others need to undertake this to ensure the practice they adopt is in keeping with safe and acceptable practice. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. Progress has been made to improve arrangements for service users to have access to health care professionals. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Discussions and comment cards from staff indicated the work is, at times, challenging. They felt that they would now be supported through regular supervision and open access to the management team. The staff induction training and process need to be developed so that they are in keeping with skills for care specification so that the content is comprehensive and prepares staff to undertake their role as care assistant. Staff monitor service users’ health through observation and conversation. Potential problems and complications are identified and dealt with through referral to the Community Psychiatric Nurse, Doctor or other specialist. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 17 Optical tests are arranged. Chiropody is available The record keeping must be improved to clearly Arrangements are made for service users to attend is facilitated through reminders and the making of service users. at the local health centre. detail these interventions. healthcare checkups. This appointments on behalf of Service users are identified prior to medication administration by the use of photographs attached to the medication administration records which is good practice and assists in identification. The inspector noted significant improvements in the standard of medication received by the home and the stock retained. The home has a medication policy; staff members, when questioned, were unaware of the contents of the medication policy. The policy does not reflect actual practice in the home. Examination of the medication administration records identified that, on occasions, medication was not signed as having been administered. The date the medication was received and the quantity was not included on the record. The person receiving medication had not signed the record. Four staff with responsibility for medication administration have received training in medication handling and administration. However, the home does not carry out any formal assessment of carer competency. None of the residents who were living at Clyde House were in charge of their own medication for various reasons, such as: not wishing to take the responsibility or mental health problems. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. The lack of recording in the complaints record does not confirm the effectiveness of the complaints procedures. All staff have not had training in adult protection procedures, potentially putting service users at risk from abuse. This judgement has been made using available evidence, including a visit to this service EVIDENCE: The procedures in the home are to be reviewed and amended to reflect good practice and routines. Service users at the home commented on the quality of service provision as a matter of routine. Staff said they listen to service users’ comments and, where they are able, address and deal with their views. The service user guide will, when amended, be provided to service users and the complaints procedure will be included. A complaints book is in place to record service users’ comments and the actions taken to address the areas of concern. There are no recent entries within the record. The registered person has had other priorities and has taken service users’ views on board and, wherever possible, has responded to the comments made. The appointment of the acting manager will assist in the development of the recording systems. There had been no complaints since the last inspection. Service users told the inspector that they knew who to complain to and felt that their complaint would be dealt with. There had been no complaints received by the Commission for Social Care Inspection. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 19 A number of care staff had undertaken training in adult protection as part of their National Vocational Qualification training. A training matrix detailing those staff who had undertaken this training was made available at the fieldwork visit. All staff need to undertake adult protection training to safeguard service users. There has been one adult protection matter reported to CSCI, which was investigated by the local authority, and a meeting arranged, in line with procedures, to discuss the best way forward. The investigation and meeting concluded that the allegation was unsubstantiated. The matter was dealt with sensitively by the home, taking into account the views and opinions of the service user. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. The home was maintained and decorated to a minimum standard and, for the most part, clean. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The registered person has undertaken an audit of the building and its fixtures and fittings, and has commenced a refurbishment of the home. New beds have been purchased for a number of service users and where others are needed, these are being purchased on an ongoing basis. New carpets have been ordered for the lounges, hall and staircases, which are in need of replacement. The wooden flooring in the hall and the smaller of the two lounges are to be retreated and stained in forthcoming weeks. The shower room on the ground floor has also received attention to the tiling, which improves the appearance and feel of the room. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 21 A number of service users’ bedrooms have been highlighted as needing replacement carpet and some need remedial work undertaken to the furnishings. This again is in hand and the work is expected to be started in forthcoming weeks. New bedding and curtains have also been purchased in flame retardant material as an additional safeguard to service users. Smoking in bedrooms is being looked at and some service users have agreed not to smoke in their rooms, although this does occur on occasion. The registered person continues in her efforts to attempt to eradicate this as a means of safeguarding service users. The cellar stairs, which lead to the laundry, have received attention, which eradicate the health and safety issues when service users or staff use the steps. The cellar area is also to receive attention in its décor and research is being carried out on how best to use this area. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. Care staff were in appropriate numbers to meet the needs of service users and recruitment procedures ensured that service users were protected. There are insufficient dedicated laundry, domestic and cooking staff. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: There have been some changes to the staff team since the registered person purchased the home in April 2006. Advertisements have been made to recruit additional staff who are interested in developing their skills in caring for service users with mental health needs. Domestic and laundry staff are also to be recruited to ensure that the home is kept to a clean and hygienic standard. There is currently one domestic who works 16 hours each week. A duty roster is in place and details the names of staff on duty. The roster needs to include the actual hours night staff are working and the role for which staff are employed. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 23 Staff are beginning to obtain the skills, guidance and direction needed to support them in their role as carers. Although all staff have not yet received one to one supervision, this has commenced and it was reported that it was the acting manager’s intention to carry out staff supervisions with all staff in his first few weeks of employment. Staff indicated, “The home is very much hands on now which makes staff feel more positive.” Examination of a sample of the most recently appointed staff files evidenced the recruitment and selection procedure had been followed and the files were, in the most part, in order. Attention needs to be taken to ensure all necessary checks are obtained prior to staff commencing employment. This practice safeguards service users and staff. Staff are receiving some in-house induction training, however the format does not meet Sector Skills specifications. This is to be researched by the home and induction and foundation training are to be provided to staff. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. Service users have a say in how the home is run but they are not fully safeguarded by health and safety practices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: An acting manager has been appointed to the home and although it is very early days has had an opportunity to identify the work that needs to be undertaken to improve the service and how this will be done. It is the registered person’s intention to spend less time at the home and provide the acting manager with an opportunity to manage the home and the service provided. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 25 A service users’ meeting has been arranged and their views and opinions have been taken on board to assist in the development of the service provided by Clyde House. Regular service user meetings are scheduled for future months. The records detailing the fire safety checks were not up to date and fire drill training records did not demonstrate that all staff had received fire drill training. This needs to be addressed to safeguard service users and staff. The records detailing service users’ personal monies have been improved upon and service users are now signing an individual record to maintain privacy. The collation of receipts needs to be looked at to ensure all purchases made on behalf of service users are accounted for. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 26 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 2 2 2 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? New Service 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 YA1 Regulation 4&5 Requirement The registered person must provide a statement of purpose and service user guide to all current and new service users. The registered person must undertake a complete and thorough assessment on service users before agreeing to accommodate them and record this on the homes assessment proforma. The registered person must ensure that all service users have a terms and conditions of residency with the home. The registered person must prepare a written plan as to how a service users health and welfare needs are to be met and keep the care plan under review. The registered person must develop the recording of risk in service users care plans, review and record any additional identified risk. Timescale for action 31/10/06 2. YA2 14(1)(a) 31/10/06 3. YA5 Sch4(8) Reg 5(3) 15(1) 15(2)(b) 31/10/06 4 YA6 31/10/06 5 YA9 12 31/10/06 Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 28 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. 6 Standard YA14 Regulation 16(2)(m) (n) Requirement Timescale for action 31/10/06 7 YA17 16(2) Sch 4(3) 8 YA17 18 9 YA20 13(2), 18(1) The registered person must consult with service users and others involved in their care, arrange social activities and make arrangements for them to take part in local, social and community activities. Records of activity, recreation and training must be maintained. The registered person must 30/09/06 amend the menu to include alternative meals. A record of meals served to service users must be maintained. The registered person must 31/10/06 arrange for all staff that have the responsibility of preparing and serving food to attend food hygiene training. The registered person must 31/10/06 ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 29 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. 10 Standard YA20 Regulation 13(2) Requirement Timescale for action 30/09/06 11 YA20 13 12 YA20 13 The registered person must expand the medication policy to include the storage of medication within the home, the action to be taken if a medication administration error is identified and the storage, administration and recording of controlled drugs. Ensure that the medication policy reflects actual practice within the home and that staff members are trained in the contents of the medication policy and work to it at all times The registered person must 31/08/06 ensure that an accurately signed and dated record is maintained of all medication received in order to maintain a complete audit trail of medication. The registered person must 31/08/06 ensure that medication provided to service users for use on leave is provided in appropriately labelled containers. A risk assessment should also be completed. Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 30 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. 13 Standard YA20 Regulation 17(1)(a) Sch 3 3i Requirement The registered person must ensure that when staff members record the non-administration of medication, they do so using the codes specified on the residents medication administration records, and an additional explanation for nonadministration is recorded if required. The registered person must ensure that an accurate contemporaneous record is made of the administration of all items of medication. The registered person must maintain the appropriate number of staff on duty at all times of the day, including cooking, cleaning and laundry staff. The registered person must introduce training in line with the Sector Skills Council specifications. The registered person must provide staff with recorded supervision at least six times a year with their senior/manager. The registered person must propose to the CSCI a manager for consideration for registration. Timescale for action 30/08/06 14 YA20 17(1)(a) 30/08/06 15 YA33 17(2) Sch4 30/09/06 16 YA35 18 31/10/06 17 YA36 18(2) 31/10/06 18 YA37 8, 9, 10 31/10/06 Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 31 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. 19 Standard YA42 Regulation 16(2)(l) Requirement The registered person must ensure that receipts are obtained for all purchases made on behalf of service users and these are retained on file available for inspection. Timescale for action 30/08/06 Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA16 YA17 Good Practice Recommendations The registered person should include in service users contracts the rules and routines in the home including, for example, drugs and alcohol. The registered person should discontinue the routine of providing drinks made up in teapots that already have milk and sugar added. Service users should be encouraged and assisted to prepare their own drinks and snacks. The registered person should ensure that the list of staff members authorised to administer medicines, which includes a record of their signature and approved initials, is accurate and updated in line with staff changes. The registered person should ensure that all items of prescribed medication, including items administered by other health professionals, are detailed on the service users medication administration records. The registered person should include service users comments in the complaints/comments book and details of any investigation carried out as a consequence of the comments. The registered person should introduce an individual training and development assessment and profile for all staff. The registered person should introduce annual appraisals for staff with their line manager to review performance against job description and agreed career development plan. 3 YA20 4 YA20 5 YA22 6 7 YA36 YA36 Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clyde House DS0000066601.V305691.R01.S.doc Version 5.2 Page 34 - 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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