Inspection on 17/01/06 for The Clough Residential Home

This inspection was carried out on 17th 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

The Clough Residential Home 18/03/09

The Clough Residential Home 05/02/07

The Clough Residential Home 05/08/05

The Clough Residential Home 06/01/05

The Clough Residential Home 04/08/04

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 Clough Residential Home Chorley New Road Bolton Lancashire BL1 5BB Lead Inspector Grace Tarney Unannounced Inspection 17th January 2006 10:30 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 Clough Residential Home DS0000009285.V277624.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 Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Clough Residential Home Address Chorley New Road Bolton Lancashire BL1 5BB 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) 01204 492462 01204 495314 wendy.williams@arc-homes.co.uk Aegis Residential Care Homes Limited Mr Paul Raymond Williams, Mr Bernard Christopher Norman Roger Holmes Mrs W Williams Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 31 OP Service users to include up to 1 PD This condition is in respect of this specific service user only and the registration of the home would revert to the initial registration category once the placement has concluded. 5th August 2005 Date of last inspection Brief Description of the Service: The Clough is a detached converted property situated in a quiet residential area of Bolton, off Chorley New Road. The house is set in its own very large beautifully kept gardens. There is plenty of parking within the grounds of the home. There is easy access to Bolton town centre and the surrounding motorway network. The door at the side of the home allows a level access for wheelchair users and people who have problems climbing steps. The home provides accommodation in mainly single bedrooms, on the ground and first floor. There are 2 shared bedrooms. There is a large lounge that overlooks the garden at the front of the house plus a large dining room and attached to this a large conservatory. There is also a smaller lounge area that is known as the library. Most of the toilets and bathrooms have aids to assist any resident with a disability or mobility problem. The home is registered to provide care for 32 residents for social/residential care. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not made aware that this inspection was to take place. This was an unannounced inspection. The inspector spent 7 hours at the home. . During this time she looked at care records to check that the health and care needs of the residents were being met. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records. She also looked at how the management recruit their staff. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms to check out the care that was being provided for them. In order to obtain information about the home, the inspector also spent time speaking to 4 residents, 1 senior carer and the homes’ manager. Not all the National Minimum Standards were looked at on this visit. The Inspector looked at the Standards that had not been looked at during the last inspection. The Standards that are looked at during inspections are those that are considered to be important for the residents’ safety and well-being. What the service does well: What has improved since the last inspection? The home has made good progress in ensuring that most of the radiators throughout the home are fitted with guards. There continues to be an ongoing programme of redecoration of the bedrooms. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. The system for ensuring that all prospective residents had a detailed assessment undertaken prior to admission to the home gave an assurance both to residents, relatives and staff that a resident was only admitted if the home could meet their needs. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken, either by a senior member of staff from the home or from the professional i.e. care manager requesting their admission. The assessments were detailed and gave a clear indication of the residents’ needs and their capabilities. The assessments looked at the physical, mental and social care needs of the residents as well as the involvement if any, of their relatives. Standard 6 does not apply. The home does not provide intermediate care. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 8. The care plans did not fully reflect the support needs of the residents. The failure of staff to undertake risk assessments could result in risks and problems going unnoticed, resulting in possible harm to residents EVIDENCE: Individual care plans were in place for each resident. The care plans of 3 of the residents were looked at. Each resident had a long-term care plan in place but if they did develop any acute problems then a short-term care plan was to be implemented. Despite 2 of the residents having an acute problem (pressure sores) however, there was no short-term care plan in place. An instruction on how to care for 1 of the residents, in relation to positional changes, was documented on the multi disciplinary record. The details in relation to equipment in use were written on the long-term care plan. There was no care plan in place for the further prevention of pressure sores for the other resident. There was no evidence to show that residents/relatives had been involved in the drawing up of the care plan. Residents and relative must be involved to ensure that important and relevant information is obtained, thereby ensuring an accurate and agreed care plan is in place. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 10 There was no moving and handling risk assessment for one of the residents. There was no pressure sore risk assessment for the two residents who had pressure sores. The moving and handling risk assessment for one of the residents had not been completed fully. It stated that this resident was at risk of falls but there was no care plan in place in relation to this risk. There was no nutritional risk assessment in place for one resident. Residents were weighed on at least a monthly basis, however their weights were recorded on various documents within the care plan. They were recorded on the moving and handling assessment, the pressure sore risk assessment or the nutritional risk assessment. There needs to be a clear policy in relation to where weights are recorded. This will ensure that the weights can be accurately monitored. Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians, chiropodists and district nurses. A district nurse was visiting the home whilst the Inspector was there. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14. The home enables residents to exercise as much personal freedom and choice as possible. EVIDENCE: A discussion with the residents and care staff confirmed that the residents were able to receive visitors in private and that they were able to choose whom they see and do not see. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 12 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 & 17. The complaint system in place enabled the residents to feel that their views were listened to and acted upon EVIDENCE: A discussion with the residents indicated that there was a general awareness of how to make a complaint. The complaints procedure was displayed in the reception area. It was easy to understand and gave an assurance that complaints would be responded to within 28 days. The complaints procedure had also been given out to each resident. Residents and staff told the inspector that they are enabled and encouraged to vote in the local and general elections. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 13 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): 19,20,21,24,25, & 26. The residents lived in suitably adapted, safe, clean, comfortable and very pleasant surroundings. EVIDENCE: The inspector walked around the home. The entrance hall is very welcoming and the corridors are wide with grab rails. There was 1 unguarded radiator in the entrance hall. There is one large lounge, a large dining room and leading off from this a large conservatory. The lounge was spacious with adequate seating and adequate occasional furniture. The dining room was spacious with adequate seating. There was an unguarded radiator in this room. There is also a smaller lounge to the front of the home. This is called the library. It is a pleasant area with plenty of books and seating for approximately 9 persons. The library was comfortably furnished with tables and footstools. There was also a television, video player and a very large assortment of various books, some large print. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 14 The conservatory was also a very pleasant area. It had an assortment of seating and two televisions. There was no level access from the dining room to the conservatory, however there were 2 grab rails to assist mobility. There was also no level access from the conservatory to the patio. The Inspector was the informed that the home does have a mobile ramp to allow access. The carpet in the conservatory was quite stained. Lighting in communal rooms was domestic, sufficiently bright and positioned to enable reading and other activities to be undertaken. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were in close proximity to bedrooms and communal areas. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked. The toilets were clean and apart from 2, were suitably adapted for disabled use. One of the toilets upstairs, adjacent to the bathroom with the small bath, was not assisted. The décor in the toilet was rather dingy. Wallpaper was peeling away from the wall. The toilet in the above bathroom was also not assisted. The small bath was also not suitable for disabled access, although there were grab rails to assist getting in or out of the small bath. The majority of bedrooms were bright well decorated and very personalised. It was evident that there was an ongoing programme of redecoration and refurbishment. Several of the bedroom doors remained without an overriding door lock. The heating within the home was adequate. All the rooms were centrally heated with radiators that, apart from the entrance hall and the dining room, were suitably protected. Thermostatic control valves were in place on immersion baths and showers. Ventilation was either natural or mechanical. Hand washing facilities were in place in bedrooms, bathrooms and toilets. Clinical waste was handled appropriately and the home had a contract for the removal of clinical waste. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 15 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 & 29. The residents were cared for by sufficient numbers of staff that were suitably experienced and trained and therefore had the knowledge and skills to meet the residents’ needs. The inadequate recruitment procedure was placing residents at potential risk. EVIDENCE: Examination of the duty rotas and a discussion with staff and residents identified that there was sufficient care staff on duty to meet the needs of the 27 residents. The home remains without a laundry assistant but the Inspector was informed that this is about to be addressed. The personnel files of three staff members were inspected. One fairly recently employed staff member had brought her criminal records bureau (CRB) disclosure check from her previous employment. Another staff member had been employed before her CRB disclosure check had been returned and a POVA first had not been applied for. This is not acceptable and not in accordance with legislation. Inspection of the references for one of the staff members identified the following: One of the references was from her last place of employment but not from the actual employer. Management must ensure that they obtain, wherever possible, references from employers and not from work colleagues or friends. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 16 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): 33 36 & 38. Current practices within the home in relation to the maintenance of a safe environment, promoted and safeguarded the health, safety and welfare of the people using the service. EVIDENCE: The company as a group were in the process of being re-accredited for the Investors in People award. The home has an annual development and business plan for the home and there was evidence of continuous self-monitoring using an objective method. An audit of the bedrooms was being undertaken whilst the Inspector was at the home. The home also undertakes a regular health and safety audit. Questionnaires are sent out on a regular basis to the residents and their relatives, and the results are collated, analysed and displayed on the homes notice board. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 17 Formal supervision had not yet taken place at least 6 times in any one year, however the inspector was made aware that senior staff were undertaking supervisory development training. A new format for documenting supervision had been implemented. The Inspector saw evidence to show that detailed appraisals of staff were being undertaken. Most of the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. There was, however, no documentation to show that the following had been serviced: The portable appliance tests (PAT). The thermostatic control valves. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 2 x 3 2 2 3 STAFFING Standard No Score 27 2 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x 2 x 2 The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 19 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 2 Standard OP7 OP7 Regulation 15 15 Requirement A care plan must be in place to address any identified problem. Residents and relatives must be involved in the drawing up of the care plan to ensure that important and relevant information is obtained thereby ensuring an accurate and agreed care plan is in place. Risk assessments must be in place for all residents in relation to nutrition, pressure sores and moving and handling. Grab rails or other suitable aids must be provided to the 2 unassisted toilets identified in this report. The decor in the upstairs toilet identified in this report, must be attended to. To ensure the privacy and dignity of the residents is upheld locks must be fitted to the remaining bedroom doors. The locks must be suited to service users capabilities and accessible to staff in emergencies. Residents must be provided with a key unless their risk DS0000009285.V277624.R01.S.doc Timescale for action 31/01/06 31/03/06 3 OP8 13 31/01/06 4 OP21 23 31/03/06 5 6 OP21 OP24 23 23 &12 31/03/06 31/03/06 The Clough Residential Home Version 5.1 Page 20 7 OP25 13 8 9 OP27 OP29 18 19 & Schedule 2 10 OP36 18 assessment suggests otherwise (The previously agreed time frames of 31/3/05 and 30/11/05. were not complied with) The radiators in the dining room and entrance hall must be guarded, or low surface temperature radiators fitted. A daily laundry assistant must be provided. Staff must not be employed until their CRB disclosure check has been returned or a satisfactory POVA first has been applied for and received. Management must ensure that they obtain, wherever possible, references from employers and not from work colleagues or friends. Formal supervision must take place at least 6 times in any one year, Evidence of progress must be forwarded to the CSCI Evidence of portable appliance and thermostatic control valve testing must be forwarded to the CSCI. 31/03/06 31/03/06 18/01/06 31/01/06 11 OP38 13 & 23 31/01/06 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 Refer to Standard OP8 OP21 Good Practice Recommendations To ensure that weights can be accurately monitored there should be clear guidance in relation to where they are to be recorded. Consideration should be given to replacing the small bath with a disabled access shower facility. The Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Clough Residential Home DS0000009285.V277624.R01.S.doc Version 5.1 Page 22 - 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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