Inspection on 24/01/06 for Radcliffe

This inspection was carried out on 24th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Radcliffe 11/01/07

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 24th January 2006 09:45 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.V251198.R01.S.doc Version 5.1 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.V251198.R01.S.doc Version 5.1 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 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.V251198.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 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.V251198.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during a six and a half hour period. A tour of the building took place and a sample of records kept by the home was looked at. Some residents and staff were spoken with. The manager of the home helped with the inspection. The inspection was a positive one as some of the issues raised at previous inspection had been dealt with. Feedback from residents and staff was good. What the service does well: 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. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 6 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.V251198.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9. The systems and procedures operated by the staff at the home make sure that the assessed needs of the service users are set out in a plan of care. The home’s policy and procedure for medication must be followed consistently. EVIDENCE: Some residents said that they were satisfied with the level of care and support that they receive from the staff. A relative made positive comments regarding the standard of care at the home. The manager has taken action since the last inspection and the care plans now include general information in relation to oral hygiene needs. Where an assessment for tissue viability indicated a high risk there is a plan of care. The manager has worked hard to ensure that the resident or their representative is involved in the review of their plan of care. The medication records were examined for three residents. The PRN medication, which is taken as and when required, could not be reconciled with Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 9 the two of the records kept. A discussion took place with the manager regarding suitable arrangements for the safe disposal of some medication. The staff must follow the policy and procedure for the safe administration and disposal of medication. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,15. The residents are supported to make choices in their lives. The residents are offered a varied diet and specialist diets are catered for. EVIDENCE: The manager said that the residents are supported to handle their own finances should they wish to do so. During a tour of the home some of the residents rooms were seen and were personalised with the residents possessions. The residents commented that they are able to choose what they ate, when they went to bed and when they got up. The residents said that they were satisfied with the food provided at the home. The residents are asked on a daily basis as to choice of food and there is currently a two weekly menu. However, the cook is in consultation with the residents regarding the planning of new menus. Specialist diets are catered for and the home currently provides diabetic, gluten free and soft diets. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. The residents live in an environment that is generally clean and tidy. It is decorated and furnished in a domestic manner. EVIDENCE: The home was generally clean and tidy on the day of this unannounced inspection. The home now has a separate smoking area for the residents that is newly decorated and well ventilated. The lounge has been redecorated and refurbished with new easy chairs, a new carpet and curtains. The dining room has been redecorated and the manager is assessing the lighting in this room. A resident’s room has also been redecorated since the last inspection. The kitchen was generally clean and well organised. A discussion took place with the manager regarding the implementation of a cleaning schedule for this area of the home, and a recommendation is made in this matter. A window was noticed to need restrictors, which would prevent people falling out of the window. The manager was made aware of this, as the issue must be addressed. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 13 The home complies with requirements of the environmental health department and generally with fire safety. New fire doors have been fitted to the central areas of the original building, however there is an external fire door in need of some adjustment to meet fire safety standards. Arrangements have been made to address this problem although a requirement has been made that this is completed within the timescale set. The manager said that there are plans to refurbish the original areas of the home later this year. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30. The manager has worked hard to ensure the staff receives the training appropriate to their work. The recruitment practices are sufficiently robust in order to protect the residents. EVIDENCE: Eight of the staff have achieved the NVQ level 2 and level 3 certificate and another eight staff are currently working towards this qualification. The manager is trying to enrol the remaining staff to NVQ level 2 training. Following a requirement at the last inspection, the manager has taken action to ensure that all the staff completes adult protection training. Following a recommendation from the last inspection the manager has worked hard to ensure that all staff receives annual movement and handling training. Two staff files were audited and these records were satisfactory. The recruitment practices are sufficiently robust to protect the residents. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The manager is registered with the Commission and she understands her responsibilities in relation to the safe and effective operation of the home. Generally the home is run in the resident’s best interests. The financial systems in place are not sufficiently robust. EVIDENCE: The manager of the home is Janet March. She is registered with the Commission for Social Care Inspection and has achieved the Certificate in Management and Health and Social Care. During this unannounced inspection the manager was noted to be approachable and have a good working relationship with both the residents and the staff. The manager said she is working towards developing the quality monitoring system in the home. There are consumer surveys ongoing in the home and the Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 16 manager regularly seeks the views of the residents and their relatives. Positive comments were noted on the surveys looked at by the inspector. The financial records for four residents were audited. Two of the financial records could not be reconciled with the monies kept and this was discussed with the manager and the provider of the home. The home must have systems in place that maintain accurate, up to date and detailed financial records. Standard 38 was addressed following a previous requirement. The requirement from the last inspection regarding the recording of all the homes hot water temperatures has not yet been addressed and is carried forward. Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 X X 1 Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 18 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 OP9 Regulation 13 (2) Requirement Timescale for action 28/02/06 2. OP19 23 (4) (b) 3. OP19 14 (4) (a) 4. OP35 17 (2) sch 4–9 The homes policy and procedure for the recording, handling, safekeeping, safe administration and disposal of medication must be followed. Previous timescale 30/09/05 not met. The registered person shall after 28/02/06 consultation with the fire authority provide adequate means of escape. Works to the identified fire door must be completed by 28/02/06. The registered person shall 28/02/06 ensure that all parts of the home to which the residents have access are so far as reasonably practicable free from hazards to their safety. Window restrictors must be fitted to all resident’s rooms. The registered person shall 28/02/06 maintain in the care home the records as specified within the regulations. As part of the action plan for this inspection report the registered person should supply the CSCI with details of the financial systems operated DS0000026287.V251198.R01.S.doc Version 5.1 Radcliffe Page 19 within the home relating to the residents monies. 5. OP38 13.4 The hot water temperatures must be checked and recorded. Previous timescale 30/09/05 not met. 28/02/06 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 OP19 OP28 OP33 Good Practice Recommendations A cleaning schedule should be implemented in the kitchen. The staff in the care home should continue working towards achieving NVQ level 2 qualification. 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.V251198.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Radcliffe DS0000026287.V251198.R01.S.doc Version 5.1 Page 21 - 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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