Care Home: Clifton Manor Care Home

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What the care home does well People are assured that their needs will be assessed before they make a decision to move into the care home and that staff can meet these. The personal and health care needs of people using the service are met and their privacy and dignity are maintained. People using the service told us, `the staff are very good and look after me,` and `the staff help me when I need a hand.` Two relatives spoken with also state that their relatives` needs are met, `they are always kept clean and tidy,` and `I have no concerns at all about the way my mother is looked after.` People using the service told us that there are no restrictions on visiting and visitors may be received in private should they wish. We saw several visitors entering the home throughout the day and one visitor told us, `I feel comfortable here, I am able to relax more here than at home, it is like home from home, it is good as I am able to look after myself and come to spend time with my wife whenever I want, I come everyday and have my lunch here, the staff are very kind.` People using the service are assured that their complaints will be listened to and acted upon and that they are protected from abuse. People using the service live in a clean and comfortable environment. People are supported by sufficient numbers of staff who are well trained to carry out their job role. People live in a service which is well managed where they are supported to express their views and opinions about the way in which the service is run. What has improved since the last inspection? The terms and conditions of admission have been updated to ensure that they contain all the necessary information a person may require to make an informed decision about whether to move into the care home. Plans of care are updated following reviews to ensure that these are current and people`s needs are met. Some improvement has taken place in regard to risk assessments and management plans working towards ensuring that people using the service are fully protected. Some development has taken place in regard to ensuring that plans of care are personalised to ensure that people receive their care in their preferred way. The guidance in regard to safeguarding people from abuse has been updated and made available for staff to ensure that this is put into practice and people are protected. Staff personnel files now contain all the required documentation by law to ensure that people are protected from unsuitable people being employed. Registered nurses professional identification numbers are now available for inspection to demonstrate that they are registered to work in the care home, thus ensuring that people using the service are fully protected. What the care home could do better: Staff must be made aware of people`s need on admission at all times to ensure that they have sufficient information available to enable them to support people appropriately. Further development of risk assessments and management plans must take place to ensure that all highlighted risk are managed and reduced to ensure that people using the service are fully protected. Medication directions must correspond with the prescription to ensure that people using the service receive the correct amounts of medication. Further consultation must take place with people using the service, having due regard to their mental health care needs, to ensure that their interests are maintained and a programme of stimulating activities are available to them. Consultation with the Environmental Health Officer must take place in regard to safe temperatures of food delivery to people using the service to ensure that they receive a meal that is appealing and they remain safe. Consultation with the Fire Authority must take place in regard to staff undertaking fire drills at the required intervals to ensure that people using the service are protected. CARE HOMES FOR OLDER PEOPLE Clifton Manor Care Home Rivergreen Clifton Nottingham NG11 8AW Lead Inspector Karmon Hawley Unannounced Inspection 23rd October 2008 09:15 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 Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Manor Care Home Address Rivergreen Clifton Nottingham NG11 8AW 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) 0115 984 8485 0115 984 5859 clifton.manor@hotmail.co.uk clifton.manor@hotmail.co.uk Monarch Healthcare Ltd Eileen Teresa Spence Care Home 30 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (30), of places Physical disability (2) Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Clifton Manor Nursing Home is registered to provide accommodation and personal care to people of both sexes whose primary care needs fall within the following numbers and categories:Old age, not falling within any other category (OP) 30 All service users falling within the category of OP must be aged 65 years and over A maximum of 12 beds out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate people over the age of 65 years whose primary care needs are Dementia (DE) A maximum of 2 beds out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate people whose primary care need is Physical Disability (PD) All service users falling within the category PD must be aged 55 years or over One bed out of the 30 registered at Clifton Manor Nursing Home may be used to accommodate a named individual with PD who is under the age of 55 years (See the registration record dated 19/05/06 and the letter dated 19/04/06 within the variation application dated 28/03/06 for the identity of the service user) The communal space on the first floor at Clifton Manor Nursing Home must be used as additional space to that on the ground floor 8th November 2007 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Clifton Manor Care Home (Nursing) is situated in the suburb of Clifton, southeast of Nottingham city and shares a site with its sister home, which provides residential care only. The home was purpose built and the accommodation is over two floors with a vertical lift to provide easy access. There are three lounges used by people using the service, one of which is designated for people who have Dementia. There is a garden and patio area at the rear of the home. The home provides personal care and nursing care to up to 30 older people, there are twelve beds, which may be used by people with Dementia, and two may be used for people with physical disabilities. The service complies with its conditions of registration. The fees for the service range from £329.83 to £9591.95 per week, the cost varies according to the dependency needs of the person. This information and the terms and conditions of the service are made available upon the point of enquiry. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star this means that people who use the service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people living at the home and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One regulatory inspector conducted the unannounced visit over 1 day, including the lunchtime period. We were joined by an Expert by Experience who is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Experts by experience do not need to have experienced an identical service. What matters is that they know what it is like to need a service. The expert by experience visited the home for two and a half hours and spoke with five people using the service and two visitors. A review of all the information we have received about the home was considered in planning this visit and this helped decide what areas were looked at. The main method of inspection we use is called case tracking which involves selecting the care plans of 4 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The manager, 3 members of staff, 5 people who use the service and 2 visitors were spoken with as part of this visit. A partial tour was undertaken by the regulatory inspector, which included looking at the bedrooms of those people who we case tracked and communal areas of the home. The service returned the Annual Quality Assurance Assessment to us in the required time scale. This gives us information about the service, the developments that have taken place and the work that they intend to do in the future. We used some of this information within the report. What the service does well: Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 6 People are assured that their needs will be assessed before they make a decision to move into the care home and that staff can meet these. The personal and health care needs of people using the service are met and their privacy and dignity are maintained. People using the service told us, ‘the staff are very good and look after me,’ and ‘the staff help me when I need a hand.’ Two relatives spoken with also state that their relatives’ needs are met, ‘they are always kept clean and tidy,’ and ‘I have no concerns at all about the way my mother is looked after.’ People using the service told us that there are no restrictions on visiting and visitors may be received in private should they wish. We saw several visitors entering the home throughout the day and one visitor told us, ‘I feel comfortable here, I am able to relax more here than at home, it is like home from home, it is good as I am able to look after myself and come to spend time with my wife whenever I want, I come everyday and have my lunch here, the staff are very kind.’ People using the service are assured that their complaints will be listened to and acted upon and that they are protected from abuse. People using the service live in a clean and comfortable environment. People are supported by sufficient numbers of staff who are well trained to carry out their job role. People live in a service which is well managed where they are supported to express their views and opinions about the way in which the service is run. What has improved since the last inspection? What they could do better: Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 7 Staff must be made aware of people’s need on admission at all times to ensure that they have sufficient information available to enable them to support people appropriately. Further development of risk assessments and management plans must take place to ensure that all highlighted risk are managed and reduced to ensure that people using the service are fully protected. Medication directions must correspond with the prescription to ensure that people using the service receive the correct amounts of medication. Further consultation must take place with people using the service, having due regard to their mental health care needs, to ensure that their interests are maintained and a programme of stimulating activities are available to them. Consultation with the Environmental Health Officer must take place in regard to safe temperatures of food delivery to people using the service to ensure that they receive a meal that is appealing and they remain safe. Consultation with the Fire Authority must take place in regard to staff undertaking fire drills at the required intervals to ensure that people using the service are protected. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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 Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are assured that their needs will be assessed before they make a decision to move into the care home and that staff can meet these. However in the event of an untimely admission staff may not have all the necessary information that they need to ensure that people’s needs are fully met during the initial transition stage. The service does not offer intermediate care. EVIDENCE: The manager visits people who may wish to use the service in the community to carry out a preadmission assessment to make sure that staff are able to meet their needs before a decision to move into the care home is made. There is evidence of these assessments taking place within care files examined. One person using the service spoken with confirmed that someone had been to see them in the hospital before they made a decision to move into the care home and said that it was a smooth transition. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 10 On the day of the visit a new person arrived at the care home at the start of lunchtime. During the lunchtime meal an incident happened where care staff needed to alert registered nurses immediately. This situation was dealt with efficiently however staff had been unaware of the needs of this person as they had not received any information about them. The manager stated that staff are usually informed of people’s needs when they are admitted to the care home, however due to the timing on this day this had not taken place. Staff spoken with confirmed that they are usually informed of people’s need when they are admitted to the care home. The service does not offer intermediate care. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and health care needs of people using the service are met and their privacy and dignity are maintained. EVIDENCE: Plans of care examined showed us that these are in place for all highlighted needs to ensure that staff have enough information to be able to support people appropriately. Some development has taken place to make these more person centred so that people receive care in their preferred way. We saw that risk assessments have also developed to ensure that these are in place for the use of bedrails and the risk of entrapment. However risk assessments are not in place for some highlighted risks following assessments, such as infection control, nevertheless no entries of concern have been recorded in daily records. Staff spoken with are able to discuss the needs of people using the service and how they support them in meeting these, they are aware of each person’s individual likes and dislikes in regard to their care. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 12 People using the service told us, ‘the staff are very good and look after me,’ and ‘the staff help me when I need a hand.’ Two relatives spoken with also state that their relatives’ needs are met, ‘they are always kept clean and tidy,’ and ‘I have no concerns at all about the way my mother is looked after.’ There is evidence within plans of care to show that people have access to specialist services such as the doctor, district nurse and chiropodist. During the tour of the care home we also saw that specialist equipment such as beds and chairs are available for people. One person using the service said that they can see the doctor at any time if they are unwell and staff spoken with confirmed this. All staff who administer medication have received the necessary training to do so. Medication practices examined showed us that people using the service receive their medication when prescribed by their doctor. Medication charts are clear, however handwritten entries on one chart had not been signed by two members of staff to show that this had been checked as correct. Also on checking one person’s medication against the prescription this had different instructions on it. The registered nurse told us that this was because it was stock that had been delivered to the home before the prescription amount had changed. This was remedied immediately to ensure that both directions are the same and the person receives the correct medication. Staff spoken with were are able to discuss how they maintain people’s privacy and dignity and gave examples such as covering people when supporting with personal care and knocking on people’s doors before entering. People using the service told us that staff are very good and respect their privacy and dignity at all times. We observed staff treating people in a kind and caring manner and asking after of people’s welfare. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of evidence available to show us that everyone using the service is supported and enabled to life a full and satisfying lifestyle that meets their needs and expectations. Carers tend to concentrate on people’s physical wellbeing rather than their mental health needs. EVIDENCE: An activities coordinator works at the care home on a part time basis, delivering activities such as bingo, reminiscence, hand massage, light therapy, music, darts and ball games. Staff also support people to undertake activities during the afternoons. On the day of the visit one person was seen to enjoy a game of darts and others were seen chatting with staff, however following dinner, the atmosphere was very quite and we saw the majority of people sleeping. The manager stated that this was normal and that people would join in activities following this. She showed us a book that contained records of activities that people using the service had undertaken; this told us that most people are joining in activities on a daily basis. People using the service did said that there are some activities available if they wish to join in. Staff spoken with felt that there is enough provided for people to participate in if they wish. The activities coordinator spoke of how they aim to spend time Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 14 with people on individual basis due to their needs and that reminiscence therapy is used often with great rewards. Outside entertainers also visit the home on regular occasions. The expert by experience found that there are neither photos of activities people have been involved in nor any displays of achievement by them. This was discussed with the manager who stated that to demonstrate that people are carrying out activities she would commence doing this. They also found that everything appeared to be centred on quietness and order rather than stimulation even the quiet music playing was to meditate by rather than music that people could relate to. The expert by experience observed that there is no sign of stimulation in the care home, there is a small collection of photos of old Nottingham and a newly made tactile board, however neither were obvious nor bright enough to stimulate conversation or interest for people using the service. People using the service told us that there are no restrictions on visiting and visitors may be received in private should they wish. We saw several visitors entering the home throughout the day and one visitor told us, ‘I feel comfortable here, I am able to relax more here than at home, it is like home from home, it is good as I am able to look after myself and come to spend time with my wife whenever I want, I come everyday and have my lunch here, the staff are very kind.’ Staff told us that they treat people individually and take into account their personal preferences and rights and choices. They stated that they are aware of equality and diversity and felt that people are supported accordingly. The expert by experience saw staff understanding people’s physical needs rather that mental health needs and show a good level of care for people. They are gentle and display some affection, using Christian names and tactile measures such as stoking hands. They are aware of individual characteristic of people using the service. On examining the menu we saw that a varied diet is on offer for people using the service with choices available at each mealtime. People using the service told us that, ‘the food is good, they feed me well,’ and ‘the food is very nice.’ one person using the service told us that they do not really like English food; therefore they have an Indian meal on occasion, which they enjoyed. One relative who also eats at the care home stated that the meals are very nice. The expert by experience ate with several people using the service at lunchtime and found that the presentation of dinner was unattractive, barely warm and bland. Everyone had the same meal and pudding and did not appear Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 15 to have a choice in this. There had not been any napkins supplied which resulted in a person wiping their hands on a nearby chair. They also observed that the interaction at this time between staff and people using the service is minimal which results in them being unsuccessfully in encouraging people to eat their meal. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are assured that their complaints will be listened to and acted upon and that they are protected from abuse. EVIDENCE: One person using the service and two relatives spoken with told us that they know how to make a complaint if they need to and who to make this to, however they did not have any complaints at present. The service has received three complaints since the previous inspection in relation to, manual handling methods used by staff and the standards of care. The complaints file shows us that all of these have been investigated appropriately and resolved. Staff spoken with are able to discuss how they would deal with a complaint should one be received. The service has had one incident following a complaint about the standard of care alerted to the Local Authority, records showed us that this has been investigated and resolved. The policy and procedure in regard to safeguarding vulnerable adults and whistle blowing has been updated. Staff spoken with are able to discuss this and their roles and responsibilities and staff files show us that the majority of staff have undertaken training in safeguarding adults. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service live in a clean and comfortable environment, however this could be made more stimulating and interesting for people using the service. EVIDENCE: There are various seating areas around the care home that people may access if they wish and people may also access the garden. General maintenance and refurbishment continues to take place to ensure that the environment is comfortable and well maintained. The laundry room observed was clean and tidy as were all other areas of the care home accessed. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 18 The expert by experience saw that people’s bedrooms only had their name on them and no symbol or sign specific to them to offer recognition, these are not all locked, and therefore people who may wander could access these. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by sufficient numbers of staff who are well trained to carry out their job role. EVIDENCE: The duty rota showed us that there is sufficient staff on duty to care and support people using the service. Staff spoken with said that the staff team work well together and that there is enough staff available to meet people’s needs. People using the service told us ‘the staff are good, they help me when I need it,’ and ‘there are enough staff here to help me.’ Two relatives spoken with said, ‘the staff team get on well, the majority of the time there are enough staff available,’ and ‘there are enough staff here to make sure that my wife is kept clean and comfortable.’ On observing staff we saw that they had very good interaction skills with people and they showed concern for them and their welfare. To ensure that all new staff are aware of their roles and responsibilities they undertake an induction when they commence employment. There is evidence of this initial training taking place within staff files examined. Two members of staff spoken with both said that their induction had been very useful and that they staff team had made them feel welcome. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 20 Staff files examined showed us that they contain all the necessary documentation required by law to ensure that people are protected from unsuitable people being employed. Staff spoken with confirmed that they had undertaken a through recruitment procedure before they commenced employment. Registered nurse professional registration numbers are available to show that nurses are registered to work. One new member of staff was working at the care home with only a POVA 1st (a check to see if a person has been placed on a list that alerts us if they have abused people in the past), the manager was not aware that people with a POVA 1st must be supervised until a satisfactory criminal record bureau check has been received, however stated that all staff work in pairs each shift. To formalise this a supervisory policy was immediately put into place and actioned. Staff spoken with confirmed that they work in pairs when on duty. Staff continue to undertake compulsory training such as manual handling, dementia care and infection control to ensure they have the necessary knowledge and skills to meet people’s needs. Staff training files examined also show us that staff undertake specialist training such as tissue viability and caring for people with diabetes mellitus. Staff spoken with said that they felt supported in their training and development needs. One relative spoken with said, ‘the staff know what they are doing, they are always cheerful and have a smile on their faces, it is a lovely home with a lovely atmosphere.’ Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a service which is well managed where they are supported to express their views and opinions about the way in which the service is run. EVIDENCE: The manager states that she remains up to date with all necessary training to ensure that she runs the care home effectively. Relatives spoken with all stated that the manager is approachable at all times and that they could talk with her if they have any problems. Staff spoken with also state that the manager is very supportive and approachable. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 22 People using the service and relevant others are given an opportunity to express their views and opinions of the service by way of annual questionnaires, reviews and meetings. A recent survey that included, people using the service, relatives, staff and visiting professionals has taken place. The results show us that everyone feels that the service is meeting people’s needs and offer the following comments: ‘the staff are very friendly and helpful,’ ‘the staff are friendly, supportive and I feel secure here,’ ‘the food is very good,’ ‘the home has improved a lot because of good management,’ and ‘the home is bright and clean with a nice outlook.’ We saw that an action plan has been put together to address any issues that could be developed. The manager carries out monthly audits on areas such as the environment and staffing to ensure that the quality of the service is maintained. So that people can access their money when they need to all, the required information as to who is responsible for this is within people’s plans of care so that staff are aware of these arrangements. To ensure that people’s personal allowances are protected there is a facility to have these kept in the care homes safe. Three people’s personal allowances checked correspond with the accounting sheet. Receipts are available for all transactions and these are signed by two members of staff. Staff spoken with stated that people can access their money at any time they like. Staff files examined showed us that staff undertake supervisions on a regular basis and discuss their training and development during these times. Staff spoken with confirmed that these take place and that they are useful. We saw that routine checks on the fire alarm systems take place to ensure that these are in working order at all times. However on checking these we found that staff have not carried out any fire drills to ensure that they have practiced in the event of a fire occurring. The manager stated that some of this is covered within their training, however she would contact the Fire Authority for further information and advice. Monthly audits take place for all accidents that have occurred to ensure that preventative measures can be put into place for people to prevent these happening again should they need to be. The annual quality assurance assessment told us that routine maintenance and servicing of equipment is taking place. We examined the hoist, lift and gas certificate on the day of the visit, which confirmed this. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 12(1,a,b) Requirement Staff must be made aware of people’s need on admission at all times to ensure that they have sufficient information available to enable them to support people appropriately. Further development of risk assessments and management plans must take place to ensure that all highlighted risk are managed and reduced to ensure that people using the service are fully protected. Medication directions must correspond with the prescription to ensure that people using the service receive the correct amounts of medication. You must further consult with people using the service, having due regard to their mental health care needs, to ensure that their interests are maintained and a programme of stimulating activities are available to them. You must consult with the Environmental Health Officer in regard to safe temperatures of food delivery to people using the DS0000026432.V372879.R01.S.doc Timescale for action 30/11/08 2 OP7 13(4,c) 30/12/08 3 OP9 13(2) 30/11/08 4 OP12 16(m,n) 30/01/09 5 OP15 16(i) 30/11/08 Clifton Manor Care Home Version 5.2 Page 25 6 OP38 23(4) service to ensure that they receive a meal that is appealing and they remain safe. You must consult the Fire Authority in regard to staff undertaking fire drills at the required intervals to ensure that people using the service are protected. 30/11/08 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 4 Refer to Standard OP15 OP15 OP19 OP19 Good Practice Recommendations Demonstrate that people using the service have choices in regard to the meals that they eat, to show that they are offered choices and that these are maintained. Ensure that people have the required accessories such as napkins during meal times to ensure that their dignity is upheld. Consider the use of symbols/pictures that are specific to people to aid the identification of their room so that they can find these more easily. Make the environment more appropriate for people with dementia care needs so that they find this more interesting and stimulating. Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clifton Manor Care Home DS0000026432.V372879.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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