Inspection on 16/05/06 for The Clitheroe Residential Care Home

This inspection was carried out on 16th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report 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... 09/11/05

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

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 Residential Care Home Eshton Terrace Clitheroe Lancashire BB7 1BQ Lead Inspector Mrs Pat White Unannounced Inspection 16th May 2006 10:00 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 The Clitheroe Residential Care Home DS0000061349.V287717.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. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Clitheroe Residential Care Home Address Eshton Terrace Clitheroe Lancashire BB7 1BQ 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) 01200 428891 01200 442166 admin@primecarehomes.co.uk Prime Care Homes Limited Mrs Jean Marie Wooff Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 9th November 2005 Date of last inspection Brief Description of the Service: The Clitheroe provides care and accommodation for 28 older people aged 65 years and over. Prime Care Homes Ltd owns the home. Mrs Jean Wooff is the registered manager. The house is a detached property located in a residential area, near to town centre shops and facilities and close to a bus route. There is a car park and enclosed patio area with garden seating at the front. Inside, the home provides bedroom accommodation on 3 floors, linked by a passenger lift. Altogether there are 18 single bedrooms (one with an en-suite) and 5 double bedrooms (with privacy screening), a “two part” lounge, a conservatory and two dining rooms. Various adaptations and equipment (such as handrails and toilet aids) are provided to assist service users with independence and mobility. Current fees for accommodation at the home are £310.50 - £350 per week, with additional charges for hairdressing, toiletries, magazines and papers. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced “key” inspection, the purpose of which was to decide an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People and checking the progress made on the matters that needed improving from the previous inspection. The inspection took about 12 hours and involved: talking to residents (eight were spoken with in some depth), touring the premises, observation of life in the home, looking at residents’ care records and other documents, discussion with members of staff and discussion with the registered manager, Mrs Jean Wooff. In addition 18 comment cards completed on behalf of residents were received and the views stated are included in the report. The views of seven relatives and the District Nursing team expressed on comment cards are also included in the report. What the service does well: Residents felt they were well looked after in the home, and they spoke highly of the manager and staff. Residents said they liked living at The Clitheroe. One resident described the manager as “marvellous” and another said that staff “would do anything for you”. One resident said everything was good and “what more could she want”. Another said she had no grumbles at all and “wouldn’t want to live anywhere else”. Residents have consistently praised the food served, and all those who completed the comment cards stated that they enjoyed the meals. One resident said the “cook is very good”, There was a good programme of varied activities such as a “day at the races” and trips out round the local countryside. Residents appreciated the activities and said there “was a lot going on”. The home was warm, clean and bright and had suitable standards of décor and furnishing. Equipment and adaptations helped residents to be independent. Residents thought their private bedrooms were nice and comfortable. One resident said how much she enjoyed being in her bedroom in the evening. The home was a safe place for residents and staff. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 6 The home’s training courses for staff made sure that they were properly trained to look after the people who lived in the Clitheroe. What has improved since the last inspection? What they could do better: The written information about the home referred to above should be made widely available to interested people and the Service User Guide must be given The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 7 to each resident and/or their relatives so that they have personal information for their own use. The written information that carers need to help them look after residents could also be further improved. There should be more information about some health and personal care matters such as continence and the use of bed rails to make sure that the residents receive the right kind of care and are safe. Some procedures for staff to follow in the management and administration of medication still need to be written, and some procedures already followed could also be improved, for example writing clear instructions for the administration of some medicines so that staff give medication correctly. The manager should make sure that all the residents’ grumbles and concerns that need investigating and action taking, are recorded so that residents and relatives know their views are taken seriously. A few parts of the premises could be improved, such as storing equipment tidily and safely, improving a badly stained carpet and ensuring that residents are not at risk from water temperatures that are too hot. The people who run the home must make sure that enough staff have the right qualifications for working in the home according to Government guidelines. The way that staff are recruited to work in the home must be improved to help prevent unsuitable staff from working in the home. Staff must not commence work until the Criminal Record Bureau (CRB) checks and two written references have been obtained. This must be addressed as a matter of priority. The quality monitoring systems could be further improved by the analysis of all the results, and producing a report that is made available to all concerned, including the Commission. 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 Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 3 & 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The admission procedures made sure that the needs of prospective residents were assessed before admission. However this assessment did not always cover important health and personal care matters in sufficient detail. Written information about the home was available to help residents and relatives make a choice of whether or not the home would be suitable but this information was not routinely given to individuals. EVIDENCE: The home’s Statement of Purpose, Service Users Guide and standard form of Contract/Terms and Conditions had been completed according to the Regulations and the National Minimum Standards. However according to residents and staff, the Service User Guide had not yet been given to individual residents or relatives, so they did not have any written information about the home. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 10 The home’s Contract/Terms and Conditions had also been developed according to previous recommendations. Signed copies of the old one were seen on residents’ files. The residents’ records showed that assessments were undertaken with prospective residents before admission by the manager, and a social worker (if residents’ were admitted under care management arrangements) to help determine whether or not the home could meet their needs. However there was no evidence that the registered person confirmed in writing whether or not the home can meet the needs of prospective residents. This is outstanding from previous inspections and must be addressed with priority. The assessments viewed did not contain all matters of health, personal and social care in sufficient detail, such as oral care and communication needs. Staff were seen attending to the physical needs of the residents in a kind and caring manner. Residents who completed comment cards and those who were spoken with stated that they were well looked after and that staff attended to their needs promptly. One resident stated that she “liked living in the home and did not want to live anywhere else”. This resident had learned to walk again since living in the home and gave credit to the staff for helping her to achieve this. Another resident praised all aspects of the home and stated “what more could anyone want”. Staff had undertaken training in dementia to help them understand the need of residents who were confused and had memory loss. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The care plans generally contained a good level of detail in many matters and showed what action staff needed to take. However some aspects of health care were not fully recorded. Medication management and procedures were satisfactory and ensured the safe administration of medicines to residents. The residents right to privacy and dignity was upheld. EVIDENCE: The care plans of three residents were viewed, and were generally well completed with a good level of detail. There was also evidence of regular reviews and residents’ involvement in their care plans. There were moving and handling risk assessments and pressure areas risk assesments. Though for one resident with pressure areas a risk assessment had not been completed, and for another resident there was no supporting risk assessment for the use of bed rails. Also there was insufficient detail in some care plans about what staff needed to do with respect to some personal and health care The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 12 matters, for example strategies for promoting continence and how teeth were looked after. The residents’ health was promoted and monitored. District nurses were involved as necessary, and supplied relief equipment to residents’ who were vulnerable to pressure areas. Professional advice was sought about the promotion of continence. Nutritional assessments were carried out. Residents had access to specialist medical care, dentists and chiropody. Medication management and administration in the home was satisfactory and safe and there were a number of good practices. Good records were kept, and in general the Medication Administration Records (MARs) were accurately completed. Residents’ medication was verified with the General Practitioner (GP) on admission and prescriptions were checked by the home prior to dispensing. Medication storage was clean and secure, including that for Controlled Drugs. However the policies and procedures needed further development. In addition the temperature in the room where medication was stored was in excess of 30 degrees which is over the recommended maximum temperature for the storage of medication. The criteria/signs for “when required” (PRN) medication should be given, had not been clarified with the GP, or clearly defined and written down. Hand written additions and alterations to the MARs were not always signed, witnessed and dated. PRN medication that residents were no longer taking was still being prescribed and had not been reviewed with the GP. None of the residents administered their own medication. Residents who were spoken with stated that staff treated them appropriately. They praised the manager and the care staff for their attitude. All those who completed comment cards stated that their right to privacy was respected and one resident stated how much she valued quiet time in her room in the evening after tea. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. There were varied leisure activities which appeared to suit the needs and preferences of the majority of residents. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served was appetising and wholesome and suited the needs and the preferences of the residents. EVIDENCE: There were a wide variety of activities to suit the interests and capabilities of most of the residents. Records, and the homes notice board showed activities such as quizzes, board games, trips out round the local beauty spots, entertainers and reminiscence sessions. There were opportunities for contact in the local community through trips out and visitors to the home such as the Salvation Army. The care plans recorded residents’ interests. All the residents who completed the comment cards stated that suitable activities were provided and one resident stated that there “was a lot going on”. Religious preferences were recorded on some care plans, and ministers from the local churches visited to give Holy Communion. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 14 All visitors who completed the comment cards confirmed that visitors were made welcome at any reasonable time, according to the home’s visiting policy. Some residents were able to say that they felt they had sufficient choice in such matters as rising and retiring times, whether or not they could stay in their rooms, leisure activities and in the food served. Most residents had small items of furniture to personalise their rooms. The food served was nutritious and varied and was praised by the residents who were spoken with, and by those who completed comment cards. It suited their expectations and preferences. There was an option of a cooked breakfast and the main (hot) meal was served at mid day with a snack meal at tea time. Drinks and biscuits were served at times throughout the day. Staff gave assistence to those who needed it and on the day of the inspection the mealtimes appeared relaxed and unhurried. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The complaints procedure was accessible to most residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse and residents felt safe living in the home. EVIDENCE: The home had a complaints procedure that was satisfactory and could be understood by most residents and relatives. However a copy of this procedure was not given to individuals. There had been no recorded complaints since the previous inspection and none had been made to the CSCI. However day - to day grumbles and concerns which required action to be taken were not recorded. Residents spoken with and all those who completed comment cards said if they had any complaints or concerns they would talk to the manager, who they thought was very approachable and would listen to what they had to say. Several residents were keen to say they did not have any concerns or complaints and that they were very happy with the home. The relatives who completed comment cards stated that they were aware of the complaints procedure but had never had to make a complaint. The home had policies and procedures that protected residents from abuse and protected their financial affairs and ‘whistle blowers’. Staff had received “in house” training in protection and abuse issues and some staff had covered this The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 16 topic during NVQ training. Residents stated in conversation and on the comment cards that they felt safe living in the home. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 17 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, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The home was well maintained and furnished and provided pleasant, comfortable accommodation. There was equipment and adaptations to assist residents with mobility. There was a satisfactory standard of cleanliness in most areas of the home. However some bedrooms had unpleasant odours and in some bedrooms residents were at risk from hot water temperatures. EVIDENCE: In general the home was well maintained and furnished and was bright and well decorated throughout. Some empty bedrooms had been decorated. The outside of the home was also well maintained, safe and accessible for residents. As a care home registered before the National Minimum Standards were implemented in April 2002, the Clitheroe had enough space, both private/ The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 18 bedroom and communal space, to meet the needs of the residents. The home also had suitable bathing and shower facilities and WCs There was suitable equipment and adaptations in the home to assist those with mobility problems. Several residents had hoists for transfer and the bathrooms were suitably adapted. A bedroom formerly used as a double room was now being used as a single room. However some bedrooms had an unpleasant odour, district nurses equipment was left in boxes on some bedroom floors, and one bedroom carpet was badly stained. The water temperature at some bedroom sink taps was too hot despite thermostatic control devices being fitted. The home’s plumber rectified this on the day of the inspection. There were no records of temperature monitoring available. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 19 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): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence, including a site visit to this service. The numbers and skills of the staff appeared to meet the needs of the residents. The staff training programme ensured that staff team had the necessary knowledge and skills to understand the needs of the residents. However the number of staff on duty in the afternoon gave cause for concern, and staff recruitment procedures were not sufficiently thorough to ensure that unsuitable staff did not work in the home. EVIDENCE: There were only two members of care staff, including the manager, on duty from 1.00pm till 5.00pm. If need be there were additional care hours support from a member of staff whose primary role in the home was as a domestic. Whilst there was no evidence that the needs of the residents at the time of the inspection were not being met, there were concerns that at other times two members of staff would be insufficient cover for all circumstances. The CSCI is seeking information from the owner about how the number of staff required during the different parts of the day has been determined. The information supplied on the pre inspection questionnaire stated that only 39 of care staff was qualified to at least NVQ 2. The staff recruitment procedures did not comply with the legislation and did not ensure that unsuitable staff would not work in the home. In the records The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 20 viewed of the most recently appointed members of staff, one member of staff had commenced work prior to a Criminal Record Bureau (CRB) check being returned and with only one written reference. There was no record in the home of a Protection of Vulnerable Adults (POVA First) check having been obtained prior to the carer starting work. For another member of staff the application form was incomplete, with no work history, and although a referee from previous employment in care had been given this had not been obtained. In addition a CRB check had not been undertaken on a volunteer who had been working in the home. The lack of adequate pre-employment checks potentially puts service users at risk and must be addressed. This matter was the subject of a legal requirement at the previous inspection. The staff training programme had improved and had been extended to ensure that staff had the skills and knowledge to carry out their work. This training, including Induction training for new members of staff, was being developed according to Government guidelines and the needs of the residents. In addition to training in moving and handling, first aid, food hygiene and fire safety, staff had completed training in dementia, adult abuse, and ‘optical awareness’. Staff spoke positively about the training and found it useful and informative. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The home was managed by an experienced and qualified manager but there were some outstanding matters from the last inspection and new legal requirements from this inspection. Quality assusrance policies and procedures were implemented which take into account the views of residents and relatives. Residents money was managed safely and efficiently and the health and safety of both residents and staff were promoted. EVIDENCE: An experienced and qualified manager, who was registered by the Commission in 2005, managed the home. In total she had worked in the home for about 16 years and the residents and staff benefited from her experience and knowledge of the home. Residents and staff spoken with thought highly of Mrs The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 22 Wooff. One resident described her as “marvellous”. Another said she always listened. Staff described her as approachable and supportive. The owner, Mr Mahmood Ahmad, visited the home on a regular basis and provided the Commission with a report of these visits in accordance with the Care Homes Regulations. Staff spoken with confirmed that regular staff meetings were held. The installation of a surveillance camera in the office gave cause for concern and the CSCI is seeking further clarification from the owner about the covert use of this equipment. The home involved the residents, visitors and staff in the quality monitoring of the home. These three groups completed annual questionnaires. There was evidence that in 2005 the results of the staff questionnaire had led to improvements in the staff training programme and that the activities programme in the home had been improved according to residents’ wishes. However there was no written report based on the results, and the Commission had not been notified of any developments in service. The records of residents’ fees and spending money were well kept, and those viewed in detail were accurate. The system safeguarded residents’ finances. Residents’ personal records listed personal items brought into the home, including jewellery. However when items of jewellery were handed over for safekeeping, and subsequently returned to the owner or relative, the appropriate signatures (of resident/relative and receiver) had not been obtained. The home’s health and safety policies and procedures ensured that the home was a safe place to live and work. Equipment, gas and electrical appliances and installations in the home had been serviced appropriately and there was a current certificate stating that the home’s water supply was free from Legionella. There was a person competent in first aid on every shift. Fire precautions were satisfactory and staff had completed appropriate fire safety training. The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 23 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 2 2 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 17 X 18 3 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 5 Requirement A copy of the Service User’s Guide must be given to every service user and/or the relatives. All sections of the home’s assessment must be completed in detail so that there is sufficient written information in all matters of health, personal and social care. Prospective residents must be informed in writing of whether or not his or her needs can be met in the home (previous timescale of 09/11/05 not met) The care plans must include all 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, continence and risk assessments in relation to pressure areas and the use of bed rails. The medication policies and procedures must be developed and completed according to the Royal Pharmaceutical Guidelines DS0000061349.V287717.R01.S.doc Timescale for action 30/06/06 2. OP3 14 17/06/06 3. OP4 14(1)(d) 17/06/06 4. OP7 15(1) 24/06/06 5. OP9 13(2) 30/06/06 The Clitheroe Residential Care Home Version 5.1 Page 25 6. OP9 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) 10. OP25 13(3)(4) (c)(a) 11. OP26 16(2)(c) &(k) and must include: Residents’ leave/visits, Use of Oxygen, PRN and Variable dose medication, Verbal changes and Covert administration. (Recommendation at the Pharmacy inspection of the 11/05/05) The temperature in the room where medication was stored must be regularly checked so that the correct temperature is maintained. (Recommendation at the Pharmacy inspection of the 11/05/05) The criteria for PRN and variable dose medication must be clearly clarified with the resident’s GP and the signs of when it should be administered must be written down on or near the MARs Hand written additions and alterations to the MARs (transcribing) must be signed, witnessed and dated. (Recommendation at the Pharmacy inspection of the 11/05/05) PRN medication that is no longer being taken, but still being prescribed, must be reviewed with the GP. The registered person must ensure that residents are safe from the hazards of water that is too hot. Regular monitoring of the water temperatures must be undertaken and temperatures adjusted accordingly. The carpet identified must be adequately cleaned or replaced, and all parts of the home must be kept odour free The registered person must review staffing levels and demonstrate to the CSCI that the numbers of staff on duty DS0000061349.V287717.R01.S.doc 10/06/06 17/06/06 10/06/06 17/06/06 10/06/06 30/06/06 12. OP27 18(1) 12/06/06 The Clitheroe Residential Care Home Version 5.1 Page 26 13. OP28 18(1) 14. OP29 19(1)(3) meet the needs of the residents at all times. The registered person must 30/12/06 ensure that at least 50 of care staff are qualified to at least NVQ level 2 The registered person must 10/06/06 ensure that members of staff are recruited according to the Regulation, and must not commence work until CRB/POVA checks and two written references have been obtained, including those from previous relevant positions of employment. The registered person must also ensure that all parts of the application forms are completed properly. The registered person must 30/06/06 ensure that thorough recruitment procedures, including CRB/POVA checks are undertaken on all people working in the home who have regular and frequent contact with residents. This includes volunteers. (Previous timescale of 30/11/05 not met) The registered person must 30/06/06 produce a report on the quality monitoring exercises, which clearly demonstrate how the results are used to develop services. This report must be sent to the CSCI and the results made known to those who took part. (Previous timescales of 31/7/05 & 31/01/06 not met). 15. OP29 19(1)(3) 16. OP33 24(1)(2) The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Medication reviews should be prompted on a regular basis and in line with the recommendations in the National Service Framework for Older People (This recommendation carried forward from last 2 inspections) It is recommended that a ‘complaints log’ is kept of all residents’ grumbles and matters of concern that need to be investigated or acted upon. (Repeated from the previous inspection) It is recommended that the equipment used by district nurses is stored tidily and safely and out of sight. It is strongly recommended that the registered provider reconsiders the use of the camera in the office. The registered person should make the business and financial plan for 2005 is available for inspection (34.5) (Repeated from the previous inspection) The registered person should ensure that when personal items, including jewellery, are handed over for safekeeping, and subsequently returned to the owner or relative, the appropriate signatures of owner and receiver are obtained and receipts issued. 2. OP16 3. 4. 5. 6. OP19 OP31 OP34 OP35 The Clitheroe Residential Care Home DS0000061349.V287717.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park 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. 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