Inspection on 11/05/05 for The Clitheroe Residential Care Home

This inspection was carried out on 11th May 2005.

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

The Clitheroe Residential Care... 26/02/09

The Clitheroe Residential Care... 11/09/08

The Clitheroe Residential Care... 28/02/08

The Clitheroe Residential Care... 18/07/07

The Clitheroe Residential Care... 16/05/06

The Clitheroe Residential Care... 09/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Clitheroe Eshton Terrace Clitheroe Lancs BB7 1BQ Lead Inspector Pat White Unannounced 11 May 2005 9.30 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 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. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Clitheroe Address Eshton Terrace Clitheroe Lancs BB7 1BQ 01200 428891 01200 442166 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Prime Care Homes Ltd Mrs Dorothy Mary Bowen Care Home 28 OP 28 Category(ies) of Old Age registration, with number of places The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The double room that provides less than 16 sq meters of available space is converted into single occupancy once the room is vacated by one of the current occupants. The registered person to notify the Commission so that the overall registered numbers can be reduced to 27. Date of last inspection 10 November 2004 Brief Description of the Service: The Clitheroe is registered to accommodate 28 older people aged 65 years plus. The home is a detached property, located in a residential area of the town. The home is owned by Prime Care Homes Ltd and the responsible person is Mr Mahmood Ahmad. The manager is Mrs Jean Wooff, who had worked in the home for 16 years. She was the deputy manager before being appointed as the manager in March 2005. The home provides accommodation on 3 floors, linked by a passenger lift, and has 18 single bedrooms, one with ensuite facilities, and 5 double bedrooms. Various adaptations and equipment are provided to assist service users with independence and mobility. There are 4 sitting areas, including 3 lounges, one of which is a conservatory, and a dining room. All over look the front car park and beyond to the street. There is an additional smoking room which was also used as a dining room. There is an enclosed patio area at the front of the property. The Clitheroe is close to a bus route. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a planned unannounced inspection, the purpose of which was to check the progress on legal requirements and good practice recommendations made at previous inspections. In addition the inspectors checked other matters, including some important areas of life in the home that should be inspected over the year. The inspection took 11 hours, 15 minutes, and was conducted by two inspectors, one of whom concentrated on medication matters. The inspection comprised of, talking to residents, a tour of the premises, looking at residents’ care records and other documents, and discussion with the manager and another member of staff. Seven residents were spoken with and others were observed in their routine activities. One relative was spoken with. What the service does well: The Clitheroe had good admission procedures which encouraged people to spend time in the home before making a decision about whether or not they wanted to live there. The home had a group of caring and committed staff who respected residents’ rights to privacy and dignity. The meals were wholesome, varied, “home cooked” and of suitable proportions. Some residents spoken with stated that they enjoyed the food. The Clitheroe provided an attractive environment in which to live and was conveniently located in the town. Residents stated that they were comfortable and liked their bedrooms. One resident stated that she was very pleased with her bedroom. The manager and the owner were seen as being approachable and supportive to staff. There was a person competent in first aid on every shift. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The recording of how residents’ needs are met could be further improved to include all health, personal and social care needs, such as information about pressure areas and nutrition. The management and administration of medication in the home must be improved. The home should persevere in the provision of appropriate activities. Some residents stated that there was “nothing going on” The premises could be further improved by providing more dining space so that some residents do not have to eat in the “smoking room”. There must be enough staff on duty at all times so that all the needs of the residents, including social and emotional needs, can be met, and which allows the manager sufficient time for management tasks. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 7 The safety of the residents could be further improved by not pegging open fire doors, by staff training on safe working practices and using foot rests on wheelchairs. 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 Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 & 5 The admission procedures ensured that prospective resident’s needs were assessed before going to live in the home, and helped to determine whether or not The Clitheroe could meet their needs. The physical needs of the residents were being met, but recent staffing shortages made it difficult for existing staff to meet all the residents’ needs, including social and emotional, at times best suited to them. EVIDENCE: The developments to the home’s new Statement of Purpose and Service User Guide, required following the change of ownership last year, were almost complete. These documents must be completed in order that prospective residents and existing residents have all the information they need. Records showed that residents were admitted following an in house pre admission assessment undertaken by the manager. Following this, detailed assessments and care plans were developed. However the manager must ensure that the home also obtains any social work assessments that have been undertaken prior to admission. The registered person must also confirm in writing whether or not the home can meet the needs of prospective residents. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 10 Staff were seen attending to the physical needs of the residents in a kind and caring manner. However, during the morning of the inspection, the number of staff on duty was below that required by the CSCI. Both staff and residents stated that under these circumstances the residents’ needs could not be met as quickly and fully as was desirable. Rotas showed that this had occurred a number of times over the last few weeks. One resident who spoke to the inspector stated that she had to wait too long for staff to assist her and that she had to do too much on her own. Staff will undertake an in house training course on “dementia” to assist their understanding and care practices of those residents who have memory loss and confusion. At the time of the inspection a prospective resident was spending a second day in the home to assist her and the staff in making a decision about whether or not she should live at The Clitheroe. She stated that she liked the home and thought she would be going to live there. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 11 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 standard(s) 7, 8 & 9 The care planning process had improved but not all the residents’ personal, health and social care needs were recorded. The residents’ health care needs were promoted and maintained, but this would be further enhanced by an improvement in the overall medication management in the home. EVIDENCE: The records viewed indicated that residents had individual care plans which had been developed and updated since the previous inspection. However risk assessments for skin pressure areas would benefit from more detail to indicate the level of risk, and there should be risk assessments in relation to the prevention of falls. Care plans should be reviewed at least once a month and risk assessments should be dated and reviewed. There was evidence that care plans had been signed by those residents who were able, and that some relatives had signed the care plans. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 12 Residents had appropriate intervention regarding skin pressure areas and equipment supplied by the district nurse was used. Continence assessments had been undertaken and the relevant details transferred to the care plan. The care plans would benefit from greater details on some aspects of residents’ health care, for example, oral hygiene, nutrition assessments and reviews and weight monitoring. The registered person should ensure that the home has suitable weighing scales Records showed that residents had access to GPs, occupational therapists, specialist doctors, chiropodists and opticians as necessary. Residents were seen moving around the home, many with walking equipment. Members of staff were seen moving residents in wheelchairs without foot rests. This practice must cease unless there are good reasons for not using foot rests, which are clearly demonstrated through risk assessments for individuals. Since the previous inspection some aspects of medication management had improved. However further improvements to the medication systems must be made to ensure the safety of the residents. These include: further development of the policies and procedures; completing risk assessments for those residents who administer their own medication; maintaining records of all medication entering the home; recording the administration of creams; secure storage of all medication (including creams); ensuring that labels are not altered and that prescribed medication is not given to anyone for whom it was not prescribed and ensuring that all medication is administered according to the prescribers’ instructions. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 13 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 standard(s) 12 & 15 Routines appeared flexible enough to suit individual’s expectations. The meals were varied, appetising and of suitable proportions and suited the residents’ preferences. EVIDENCE: Residents could rise and retire when they wished. Leisure activities had been reviewed and recorded in an activities book. However some residents spoken with stated that “there was not much going on”. The manager stated that residents were encouraged to take part in organised activities such as “sing a longs” and entertainers, but that many chose not to take part. Staff spoken with stated that there had been little time for activities recently, due to staffing difficulties. Residents’ leisure interests, hobbies and religious persuasion were recorded on the care plans. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 14 Two lunch - time meals were observed at the inspection. They were wholesome, tasty and of suitable proportions. The menus seen were varied, and residents were involved in their preparation through discussion with the cook. Some residents spoken with stated that they had enjoyed the lunch – time (main cooked) meal and that the food was “good”, some residents said the food was “alright”. Drinks were served at intervals throughout the day. The dining room was not large enough for all the residents to dine together. A small group of residents who required assistance had their meals separately at a table in one of the lounges, and a small group of male residents dined in a small room separate from the dining area. This was also a “smoking” room for staff. It is recommended that the registered person review this practice of residents eating their meals in the “smoking room” The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 15 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 standard(s) 16 & 18 The home had a complaints procedure that was in accordance with the Care Homes Regulations, but residents had little awareness of this. The home had policies and procedures that assisted in the protection of residents from abuse. EVIDENCE: The complaints procedure was displayed in the hallway of the home. It must be updated with respect to the name of the CSCI. No complaints had been recorded or investigated by the home and none had been made to the CSCI. The registered person should ensure that all residents’ concerns are recorded, and investigated as necessary, so that they, and relatives, are confident that these concerns are listened to and taken seriously. There had been no recent allegations or suspicions of abuse and the home had policies and procedures to support the protection of residents from abuse. The procedures must be amended according to the “No Secrets” guidance. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 21, 23, 24 & 25 A number of improvements to the décor, furnishings and facilities had enhanced the appearance and comfort of the environment at The Clitheroe. The home provided clean, attractive communal and private accommodation for the residents. EVIDENCE: The new owner was committed to improving the environment. Several areas of the home had been re decorated and carpets had been replaced and / or cleaned. The grounds were tidy and the front garden had been suitably enclosed. The garden benches should be sanded and painted. The registered person must cease the practice of pegging open the fire doors. The communal space of a lounge, a conservatory and a dining room provided residents with varied and comfortable areas. Furnishings were of suitable quality and style. One part of the conservatory was used as a smoking area. The home was short of dining space. A room adjoining the lounge was used for storing wheelchairs. It is recommended that alternative storage space be The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 17 found for wheelchairs to enable this room to be used as a lounge or dining room. A new bathroom had been completed and a new hoist purchased. There were 3 assisted baths, an assisted shower and 9 WCs. There were 18 single rooms, two of which were slightly below 10 square meters. There were five double rooms, one of which was slightly below 16 square meters. It is a “Condition of Registration” that should this room be vacated by one of the current occupants, it is to be converted into a single occupancy. The bedrooms were furnished to a high standard to ensure the comfort of the residents. Residents spoken with stated that they were satisfied with their private accommodation. Windows were fitted with appropriate window restrictors. All radiators were protected by guards, and all necessary pipe work had been covered. Documentation showed that the home’s water supply was tested and found to be safe from the risk of Legionella. The premises were clean and fresh throughout. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The home had gone through a difficult period with respect to staff shortages. There had been insufficient staff to meet the needs of the residents on a significant number of shifts in the recent past. Staff recruitment procedures were in accordance with the Care Home’s Regulations and therefore assisting in the protection of service users. The home’s staff training programme was being developed to meet the needs of the residents. EVIDENCE: On the first day of the inspection the home was short of a member of care staff from 8.00 am onwards. This was rectified the following day. Rotas showed that this had occurred a number of times in the recent past. The manager stated that this was because there were difficulties retaining and recruiting suitable members of staff to work both days and night shifts. It was also observed that the two care staff on duty took their break together in the dining room. There was not a care assistant with the residents in the lounges at this time. The manager must ensure that staff break times are organised so that residents are not left unattended. I Discussion with staff and residents indicated that staff were finding it difficult to meet the needs of the residents when the staff numbers were below the agreed levels. Some residents said they had to wait a long time for attention from staff and one resident said she had to do too much on her own. The situation was expected to improve the following week when a new member of staff was to commence work (see below). The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 19 The hours worked by the home’s cook and cleaner were also below those required by the CSCI. The registered person must ensure that the home is staffed according to the numbers required by the CSCI and according to the needs of the residents. The file of the member of staff due to commence work was viewed. This showed thorough recruitment procedures had been followed according to the Care Homes Regulations. The home had an in house induction programme, and was developing its training programme to meet the changing needs of staff and residents, including a rolling programme of moving and handling training and an in house training course on dementia. The manager should ensure that the home’s training programme is in accordance with the Skills for Care (the former TOPSS) specifications. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 & 38 There was a new manager appointed, who had many years experience of working in the home, and who had completed the relevant NVQ courses. Her ability and competence as a manager had not yet been demonstrated. The home had begun to involve the residents and relatives in the running of the home. Staff supervision procedures, and practices to ensure the safety of the residents, could be improved. EVIDENCE: The manager, Mrs Jean Wooff had been in post since March 2005. She had completed the relevant level 4 NVQ courses, and had worked in different roles at The Clitheroe for about 15 years. Since her appointment as manager there had been staff shortages, and Mrs Wooff had spent considerable time filling in for “care hours” at the expense of her management duties. The owner, Mr Mahmood Ahmad, visits the home on a regular basis and both he and the manager were described as supportive and approachable. However Mr Ahmad must ensure that someone from the registered company, not The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 21 involved with the management of the home, makes monthly, unannounced monitoring visits to the home in accordance with Regulation 26 of the Care Home’s Regulations 2001. Reports of these visits must be sent to the CSCI. The home had begun to involve residents in the quality monitoring of the home. Residents and relatives had completed questionnaires, and staff were about to complete theirs. The registered person must ensure that the results of the survey are analysed and used to inform service development. The residents and relatives and the CSCI must be informed of the outcome of such surveys. Formal one to one supervision of care staff was not taking place. The manager stated that this was due to staffing difficulties. However the member of staff spoken with stated that she felt supported and supervised at work. Equipment, appliances and installations in the home had been serviced appropriately. There was a current certificate stating that the home’s water supply was free from Legionella, and there was a person competent in first aid on every shift. However the registered person must ensure that the practice of pegging open fire doors ceases, that staff cease the practice of smoking in “non smoking” areas (including the dining room) and that wheelchairs are used with foot rests unless risk assessments determine otherwise (see standard 8). The recommendation that staff should receive training on safe working practices according to Skills for Care specifications, including infection control, is repeated from previous inspections. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 3 x 3 3 3 x STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 3 2 x x 2 x 2 The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 5&6 Requirement The registered person must ensure that the Statement of Purpose and the Service User Guides are completed and forwarded to the CSCI by the stated date.(Previous timescale of 30 January 2005 not met) Pre admission assessments under taken by social workers must be obtained by the home prior to admission.(Previous timescale of November 2004 not met) The registered person must confirm in writing whether or not the propective residents needs can be met in the home. (Previous timescale of November 2004 not met) The registered person must ensure that there are enough staff on duty at all times to ensure the needs of all the residents are met. The manager must ensure that the service users’ plan details the action to be taken to ensure all aspects of health, personal and social care needs of the service user are met, for example oral health care, Timescale for action 30 June 2005 2. 3 14 (1)(a) & (b) Immediate 3. 4 14(1)(d) Immediate 4. 4 12(1)(a) & (b) Immediate 5. 7 15 (1) 30 June 2005 The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 24 6. 8 13 (4)(b)&(c) 7. 9 13 (2) 8. 9 13(2) & 17 (1)(a) Sch 3 (i) 13(2) 17(1)(a) Sch 3 (i) 13 (2) 9. 9 10. 9 11. 9 13 (2) 12. 9 13(2) 17(1)(a) Sch 3 (i) 13. 18 13 (6) nutriton assessments and reviews and risk assessments in relation to falls. The registered person must ensure that foot rests are used on wheelchairs when transporting residents unless risk assessments demonstate the need to do otherwise The registered person must ensure that risk assessments be completed, and reviewed regularly, for all residents wishing to self-administer some or all of their medication. Records must be maintained of all medication entering the custody of the home. (The previous timescale of November 2004 not met) All administration of medication, including creams and other external preparations, must be recorded. All prescribed items must be stored safely and appropriately. Creams must not be stored in communal areas. The registered person must ensure that staff do not alter labels and on no account must prescribed medication be shared or administered to another person. (Previous timescale of November 2004 not met) The registered person must ensure that all medication is administered according to the prescribers’ instructions. Medication must not be omitted without clarification of the reason. (The previous timescale of November 2004 not met) The abuse procedures must be amended to state that the Social Services and the CSCI must initially be contacted in the event of an allegation and / or Immediate 30 June 2005 31 May 2005 Immediate Immediate Immediate Immediate 31 May 2005 The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 25 suspicion of abuse. 14. 19 23 (4)(c)(i) The registered person must ensure that the practice of pegging open of fire doors ceases (Previous timescale of November 2004 not met) The registered person must ensure there are sufficient numbers of staff, including catering and domestic staff, to meet the needs of the service users, working in the care home at all times. The manager must ensure that staff break times are organised so that residents are not left unattended. The owner must ensure that someone from the registered company, not involved with the management of the home, makes monthly, unannounced monitoring visits to the home. Reports of these visits must be sent to the CSC The registered person must ensure that the management hours are sufficient for the efficient management and development of the home. The registered person must ensure that the results of the quality monitoring survey are analysed and used to influence service development. The residents and relatives and the CSCI must be informed of the outcome of such surveys. The practice of pegging fire doors must cease The registered person must ensure that staff do not smoke in designated no smoking areas. Immediate 15. 27 18 (1) 30 June 2005 16. 27 18 (1) Immediate 17. 31 26 From the receipt of the report 18. 31 18 (2) 31 July 2005 19. 33 24 (1)&(2) 31 July 2005 20. 21. 38 38 23 (4)(c)(i) 13 (1) Immediate Immediate from the receipt of the report The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 26 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 7 7 9 Good Practice Recommendations Risk assessments in relation to pressure areas should contain sufficient detail to determine the level of risk. Care plans should be reviewed at least once a month and risk assessments should be reviewed and dated. Policies and procedures for medicines management should be reviewed and further developed in line with Royal Pharmaceutical Society of Great Britain guidelines to address all aspects of medicines management. Policies should reflect current practice. Clear procedures should be in place where necessary. A second member of staff should witness all hand written entries on Medication Administration Record charts. Staff should record the date of opening on all eye drops, creams and other items with a short shelf-life. Where drops are to be used in both eyes, separate bottles should be used for each eye to avoid cross-contamination. The temperature of medication storage areas should be recorded on a regular basis (fridge temp recorded daily). A list of staff authorised to administer medication should be kept together with a sample of their signature as it appears on the Medication Administration Record charts. Medication reviews should be prompted on a regular basis and in line with the recommendations in the National Service Framework for Older People The registered person should ensure there are enough resources, including staffing, to enable suitable activities to be sustained. The practice of residents eating in the smoking room should be reviewed. The registered person should ensure that residents concerns and complaints are recorded and investigated appropriately. It is recommended that the garden furnniture be sanded and painted. It is recommended that alternative storage space be found for wheelchairs to enable this room to be used as a lounge or dining room. The home’s training programme should be in accordance F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 27 4. 5. 9 9 6. 7. 8. 9. 10. 11. 12. 13. 14. 9 9 9 12 15 16 19 20 30 The Clitheroe 15. 16. 36 38 with the Skills for Care specifications. One to one formal staff supervision should recommence. Staff should receive training on safe working practices, including infection control, according to Skills for Care specifications. The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 28 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington BB5 5JB 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 The Clitheroe F57 F07 S61349 Clitheroe V226765 110505 Stage4.doc Version 1.30 Page 29 - 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. 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