Inspection on 11/01/07 for Radcliffe

This inspection was carried out on 11th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Radcliffe 24/01/06

Radcliffe 15/09/05

Radcliffe 11/03/05

Radcliffe 24/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Radcliffe 444 Huddersfield Road Mirfield West Yorkshire WF14 0EE Lead Inspector Bronwynn Bennett Unannounced Inspection 11th January 2007 08:45 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 Radcliffe DS0000026287.V318221.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. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radcliffe Address 444 Huddersfield Road Mirfield West Yorkshire WF14 0EE 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) 01924 493395 01924 493225 enquiries@theradcliffe444.co.uk Mr Kevin Martin Janet March Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: The Radcliffe is a care home registered to provide personal care and accommodation for up to 34 older people. There is an extension to the original building, and all the bedrooms in this extension are en-suite, and five bedrooms in the original building have en-suite facilities. All the bedrooms are for single occupancy. Residents have use of a passenger lift and a wheelchair lift in the extension of the home. Outside there is a garden and patio area with a seating area for the residents. Car parking is available. The Radcliffe is on a bus route close to Mirfield town centre and Huddersfield is within easy reach. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The visit began at 8.45am and finished at 4.05 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager. The inspector read records of people’s care, staff records, looked at how medicines are given and looked at the accommodation available in the home. Prior to this visit the Commission for Social Care Inspection sent ten questionnaires to service users living at the Radcliffe. Ten completed questionnaires were returned. There were thirty four service users living at the home on the day of this visit. Surveys were sent to nine service users’ relatives and six responses were received. Surveys were also sent to six social workers, two GP’s. Two social workers and one GP response was received. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire was completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: Service users receive sufficient information about the home prior to moving in so they are able to decide if it is the right place for them. The Radcliffe offers a warm and homely environment for service users. There were many positive comments made about the staff and the manager both during this visit and from the surveys received by the CSCI. There were comments such as “the staff are lovely” and “ the manager is very approachable”. There were positive comments received regarding the standard of food served in the home. The service users spoken to during this visit said the food was good, with a choice of meals and plenty to eat. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 6 In addition to the ongoing training being provided in the home 63 of the care staff that has achieved NVQ (National Vocational Qualification) level 2 or above. The staff team works hard to ensure the home is run in the best interests of the service users living at the Radcliffe. What has improved since the last inspection? 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. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 7 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 Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 8 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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to moving into the care home. EVIDENCE: There was information in the care records looked at that showed the needs of service users are assessed prior to admission into the care home. Seven service users who responded to the surveys said that they received enough information about the home before they moved in so they could decide if it was the right place for them. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Greater care is required to ensure all the service users health and personal care needs are recorded in the care records. Service users are protected by the home’s medication policy and procedure. Generally service users are treated with dignity and respect. EVIDENCE: The Radcliffe provides a warm and homely atmosphere. Service users spoken to during this visit said that the staff and the manager are kind and helpful. The surveys received by the CSCI indicate that the service users receive the care and support they need. There were additional comments made such as “I’m quite happy, it’s a fantastic place” and “Very satisfied with everything”. Six relatives and three health care professionals that responded to the survey said that they were satisfied with the overall care provided at the home. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 10 Service users were seen being treated in a dignified, relaxed and respectful manner by the staff during this visit. The care records for three service users were looked at. The information held in these records is generally good and provides easily accessible information for care staff to follow. However, greater care should be taken to ensure all the required information relating to service users is available. For example, the dietary needs of one individual had not been recorded in their care plan or nutritional assessment. There were risk assessments in place but were the level of risk changes this should be recorded in the appropriate risk assessment. The issues identified were discussed with the manager who agreed to take action and rectify the matter. The home’s medication system was audited. The medication for three service users was checked and correct. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. Service users are able to exercise choice and control over their lives. The home provides a varied and nutritious diet. EVIDENCE: The information from the survey showed that seven service users said there was “always” activities arranged by the home one said there were “usually” and two said “sometimes” activities are arranged. There is a choice of information about activity displayed in the home. There is organised activity such as aromatherapy, chair exercise, arts and craft and shopping trips. One service user commented that if they make a request to go anywhere or do anything it is always granted. Religious observance is respected for service users, with some individuals going out to church and religious ministers visiting individual service users on a regular basis. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 12 The manager said there are no restrictions in visiting the home. Six relatives that responded to the survey said they were always welcomed into the home by staff. Service users are supported to handle their own finances should they wish to do so, and lockable facilities are available in individual rooms for this purpose. During a tour of the home individual rooms were seen and had been personalised by service users’. During this visit breakfast and lunch was observed and meals we seen being provided in a relaxed and unhurried manner by the staff. The home’s cook has consulted service users regarding their choice of food and there is a varied menu with a choice of meals available. Eight service users who responded to the survey said they “always” liked the meals and two said they “usually” liked the meals served at the home. There were additional comments such as “ the meals are very good” and “never had a poor meal yet”. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Generally service users and their relatives are confident their complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: The home has a policy and procedure in place for dealing with complaints that is displayed in the home. Eight service users who responded to the survey said they knew how to make a complaint and nine service users said they knew who to speak with if they were not happy. Two service users spoken with during this visit said they felt able to speak to the manager should they have any concerns or a complaint. The staff spoken with during this visit had a good understanding of adult protection issues and the necessary action that must be taken should there be any allegations of abuse. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well-maintained environment that is clean and comfortable. EVIDENCE: During this visit the home was noted to be clean and fresh. All the surveys received from service users said the home is always fresh and clean. The home has an ongoing maintenance programme. Since the last visit by the CSCI there has been some redecoration to service users bedrooms and general areas. Other works include new handrails and general maintenance works carried out to the interior and exterior of the home. In addition’ the original part of the building (unit 1) is currently being rewired. The laundry facilities were seen and were clean and well organised. However, this area was not suitably equipped for hand washing. Laundry facilities should Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 15 be equipped with a sink for hand washing, antibacterial hand wash and paper towels. The laundry room floor requires repainting to ensure it can be easily cleaned. These issues were discussed with the manager who said there was some works planned for the home’s laundry facilities. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 16 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): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and receive induction and ongoing training. Service users are supported and protected by the home’s recruitment policy. EVIDENCE: Staff are employed in sufficient numbers to meet the needs of the service users living at the home. All the service users spoken to during this visit said the staff are helpful and supportive. The service users who responded to the survey said that the staff are available when they are needed. Six relative and three professional surveys received by the CSCI said they were satisfied with the overall care provided at the home. One relative commented that the staff are “first class” and their relative felt safe and well cared for. The information received by the CSCI states that there are 63 of the care staff working in the home that have achieved NVQ (National Vocational Qualification) level 2 or above. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 17 During this visit three staff files were looked at and contained the information required to ensure service users are protected by the home’s recruitment procedures. All staff have undertaken induction training and there is ongoing training for staff to ensure they receive suitable training to meet service users needs. The records looked at showed the staff has completed manual handling, food hygiene, adult protection and fire training. Some staff have received first aid training. The manager said that infection control training is being arranged for staff during 2007. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 18 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a home run by a manager who is fit to be in charge. The home is generally run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. EVIDENCE: The home’s manager is Mrs Janet March. Both service users and the staff made positive comments about the manager during this visit. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 19 The finances were checked for three service users. The money could be reconciled with the financial records kept by the home. Service users are supported to handle their own finances should they wish to do so and are provided with lockable facilities for this purpose. There is a quality monitoring system operating in the home that seeks the views of service user, their relatives and visiting professionals such as the district nurse and GP’s. The home has received positive feedback from the annual questionnaire. The manager plans to publish the findings from the quality monitoring carried out in the home. This is good practice. The information received by the CSCI shows that the equipment in the home is serviced regularly. The fire records were checked. There is weekly testing of the home’s fire alarm system and emergency lighting system. All the staff has undertaken fire and fire drill training. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 20 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 X X 3 X X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP26 Regulation 13.3 Timescale for action The registered person shall make 11/03/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Facilities for hand washing must be sited in the laundry room. Requirement 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 OP7 OP8 OP33 Good Practice Recommendations Sufficient detail of the service users’ care needs should be documented in individual care records kept. Identified risks for service users’ should be documented in the individual care records. The results of the annual questionnaire should be published and made available to the residents, their relatives, and any other interested parties including the Commission for Social Care Inspection. Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square (South) Leeds LS1 2ND 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 Radcliffe DS0000026287.V318221.R01.S.doc Version 5.2 Page 23 - 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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