Care Home: Clifton Meadows

Similar services:

• Abbey The
• Snydale Care Home
• Hawkhills
• Larchfield Manor
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well People who used the service and relatives expressed their satisfaction with the quality of care being provided. There was a good and committed staff team, which was working well together to provide a good standard of care to people living at the home.Clifton MeadowsDS0000003101.V378377.R01.S.docVersion 5.2People who lived at the home were provided with good social and recreational activities so that they could benefit from as good a quality of life as possible. Staff were being properly supported by the new manager so that they could benefit from continuing training, development, supervision and guidance. This helped to ensure that they had the required skills, values and competency to carry out their tasks. The physical environment was consistently kept in good condition and this ensured that the place continued to be safe, comfortable and pleasant. What has improved since the last inspection? The management of the home has been improved by the appointment of a new manager and of a deputy manager. Both post holders had experience of working and managing residential care for older people. There has been some improvement in the care planning process and in care documentation. People who lived at the home told us that the meals service had improved considerably and were very happy with it. There has been some improvement in the level and deployment of care staffing on one of the Units (Solway). What the care home could do better: Although some improvement has been made on the level of care staffing being deployed at the home, there was a continuing need to review the staffing levels, in particular, on the unit for people with dementia. This will help to ensure that the needs of people who use the service are consistently met. Further improvement should be made to the care planning process, including the reviewing of care and care documentation in general. This will help in ensuring that all identified needs are appropriately met. Staff should improve the way they record medicines that are received at the home. This will help in ensuring appropriate control and audit of medicines, which are kept at the home. The manager should ensure that all bulky continence and other care products are appropriately stored and are kept away from the bedrooms of people who live at the home. The registered provider should make more efforts to ensure that the care team at the home comprises of people of diverse backgrounds. This will help inClifton MeadowsDS0000003101.V378377.R01.S.doc Version 5.2 meeting the cultural and specialist needs that people using the service may have. Key inspection report CARE HOMES FOR OLDER PEOPLE Clifton Meadows Badsley Moor Lane Rotherham South Yorkshire S65 2BA Lead Inspector Ramchand Samachetty Key Unannounced Inspection 10th November 2009 09:50 DS0000003101.V378377.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifton Meadows Address Badsley Moor Lane Rotherham South Yorkshire S65 2BA 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) 01709 838639 01709 838913 jan.scott@anchor.org.uk www.anchor.org.uk Anchor Trust Manager post vacant Care Home 65 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (40) of places Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th August 2008 Brief Description of the Service: Clifton Meadows is registered to care for 65 older people, 40 of whom being in the category of old age and 25 older people with dementia. It is owned and managed by Anchor trust, which is a national voluntary organisation providing a range of services for older people. The Home is situated in the residential area of Clifton, within easy reach of Rotherham town centre and other leisure facilities, including Clifton Park and Herringthorpe playing fields. The Home consists of 2 two-storey buildings, adjacent to each other. It also shares its premises with some units of sheltered accommodation, which are provided by its parent organisation, Anchor Trust. One of the buildings (Wentworth Lounge) has been specifically redesigned to provide a service for people with dementia. All residents bedrooms are single and have en-suite facilities. Bedrooms and some communal facilities are grouped in smaller units to facilitate group living. Each building is equipped with a kitchen, a laundry, dining areas, lounges and a range of hygiene facilities. Meals are prepared in only one of the buildings and it is transported to the other building in a heated trolley. There is a passenger lift in each building to facilitate access between the floors. There are some garden areas and car parking spaces around the Home. The home has produced a statement of purpose and a service user guide. The current scale of charges, at 10 November 2009, range from £366.00 to £477.00 per week. Further information can be obtained from the home. Clifton Meadows DS0000003101.V378377.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 stars. This means that the people who use the service experience good quality outcomes. This key unannounced inspection was carried out on 10 November 2009, starting at 09.50 hours and finished at 18.30 hours. The manager, Mrs Kerry Wolfe was present throughout the inspection. The service is registered to provide care for up to 65 older people. Up to 25 places can be used for people who have dementia and these places are provided within a dedicated buildingWentworth Unit. There were 61 people in residence at the home at the time of this inspection. Twenty-three people were in residence at the Wentworth Unit. All the key national minimum standards for ‘Care Homes for Older People’ were assessed. The inspection included a visual check of the premises, examination of care documents and other records, including staff rota, medicines, complaints, policies and procedures, maintenance of equipment and quality assurance methods. The care of three people was examined and some aspects of care were observed. We gave feedback about our initial findings to the manager and other senior staff. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We would like to thank all the people living at the home, relatives, visitors and staff for their help with this inspection. What the service does well: People who used the service and relatives expressed their satisfaction with the quality of care being provided. There was a good and committed staff team, which was working well together to provide a good standard of care to people living at the home. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.2 Page 6 People who lived at the home were provided with good social and recreational activities so that they could benefit from as good a quality of life as possible. Staff were being properly supported by the new manager so that they could benefit from continuing training, development, supervision and guidance. This helped to ensure that they had the required skills, values and competency to carry out their tasks. The physical environment was consistently kept in good condition and this ensured that the place continued to be safe, comfortable and pleasant. What has improved since the last inspection? What they could do better: Although some improvement has been made on the level of care staffing being deployed at the home, there was a continuing need to review the staffing levels, in particular, on the unit for people with dementia. This will help to ensure that the needs of people who use the service are consistently met. Further improvement should be made to the care planning process, including the reviewing of care and care documentation in general. This will help in ensuring that all identified needs are appropriately met. Staff should improve the way they record medicines that are received at the home. This will help in ensuring appropriate control and audit of medicines, which are kept at the home. The manager should ensure that all bulky continence and other care products are appropriately stored and are kept away from the bedrooms of people who live at the home. The registered provider should make more efforts to ensure that the care team at the home comprises of people of diverse backgrounds. This will help in Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.2 Page 7 meeting the cultural and specialist needs that people using the service may have. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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 Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care needs of people were appropriately assessed before their admission to the home. This ensured that their identified needs could be met at the home. EVIDENCE: We checked the care files of three people who had been admitted to the home in the last twelve months. Two of the files related to people who had dementia and one to an older person who required care and support. Two of the people were funding their own care. The care files showed that assessments of needs had been carried out before their admission to the home. These assessments were carried out by both placing social workers and by staff at the home. The assessment of needs for people who were funding their own care was carried Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 10 out by the home staff. This helped to make sure that their identified needs could be catered for at the home. The home does not provide an intermediate care service. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service stated that they were satisfied with the care they were receiving. Although the planning and provision of care had improved, there were still some minor shortfalls in care planning and in medicines records. These could affect and slow down the overall improvement of the service. EVIDENCE: People who used the service and their relatives told us that they were satisfied with the care and support that was being provided. They said that staff were ‘friendly and caring’. They said that care was always provided in a way that protected their privacy and dignity. Staff explained that personal care was provided in people’s own bedrooms or in bathrooms. We noted that staff interactions with people in their care were polite and respectful. Relatives and Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 12 volunteers said that people who lived at the home were well looked after and that in their view, staff did everything to make people ‘comfortable and happy’. We looked at the care plans of three people who used the service. Two of them related to specifically people who had dementia and one to an older person who required residential care. We noted that some aspects of the care documentation were not fully completed, although the person had been in the home for several months. The care plans were based on the broad assessments of identified needs and risks. The care plans outlined actions that were required to meet the care needs of individuals. However, in some instances, particularly in the area of dementia care and mental wellbeing, these actions were not clearly stated. Therefore staff had little guidance on how to effectively meet those needs. Risks were assessed and managed. The care plans that we checked showed that the nutritional and falls risks of the individuals concerned had been assessed and managed. The care plans were reviewed on a regular basis. However, there was still a lack of information about how the reviews were carried out and the rationale for the outcomes of such reviews. People who used the service told us that they had good access to health care services. They said that staff were usually prompt in helping them with appointments to see their GPs, dentists and other health care professionals. The care plans included records of health care interventions and their outcomes. We looked at the way medicines were handled and administered at the home. Medicines received at the home were appropriately recorded and stored. We checked a sample of medicines administration records (MAR) sheets. They were generally well maintained. However, there were minor shortfalls in the way prescribed medicines received were actually recorded on the medicines administration record sheets. A number of items showed no ‘carried forward’ figure and this made the tracking of medicines administered rather difficult. Staff explained that the information about the quantity of medicines received at the home was always recorded and agreed to include it in the MAR sheets. None of the people living at the home were administering their own medicines. The manager confirmed that staff who administered medicines had received the relevant training to do so. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived at the home were able to benefit from the recreational and social facilities that were offered to them. This helped to maintain and improve their quality of life. EVIDENCE: During our visit, we observed people living at the home, spending time in the lounges and in their rooms, listening to music and watching television. On the dementia unit, a small group of people spent time in the lounge in the company of relatives, staff and volunteers. There was a ‘coffee’ morning and the volunteers were raising funds and preparing for an ‘Autumn Fair’, which would be held at the home, for the benefit of the people who lived there. People who lived at the home and who could express their views and some relatives told us that there were always a ‘lot’ of activities being organised. This helped to cater for the various tastes and preferences of people living at the home. The manager confirmed that a part-time activities coordinator was Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 14 in post and that she ensured that all the people who lived at the home could benefit from social and recreational activities. Information about such activities was prominently displayed on notice boards. Staff commented that they would also talk to people in their care and relatives about the activities being organised. The manager explained that social needs of people were also being included in care planning to make sure they were effectively met. People who lived at the home told us that they had taken part in various activities and events. They said that staff would sometimes ask them about their preferences in recreational and social activities. They said that they enjoyed the coffee mornings and the outings that were organised from time to time. People in the dementia unit were often offered one-to-one time with care workers and they would also have use of the special ‘sensory’ lounge. Relatives confirmed that they were always welcomed at the home. They felt that staff communicated well with them and with people in their care. This helped to ensure they could express their views and preferences about the way their care was provided. Staff would also help people who could not fully make decisions on their own, by working with relatives and relevant professionals, thus ensuring their welfare was promoted. People who lived at the home stated that the meals service had much improved. They said that the meals offered were ‘good and nourishing’. They commented that they were offered good choices for breakfast, lunch and dinner each day. We observed lunch being served, at the Solway unit, on the day of our visit. The dining tables were well laid out. The meal was partly plated and people were offered vegetables in tureens so that they could help themselves as far as possible. Various drinks were also offered according to people’s preferences. People who lived at the home told us that they had been well served and that they were happy with the meal. The manager explained that staff had received training on ‘dignity in care’ and that this had helped to make meal times more sociable and pleasant. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who used the service were appropriately protected from harm and abuse. Staff were able to use existing policies and procedures to safeguard people in their care and to respond to their views and concerns. However, there were minor shortfalls in the way complaints records were managed. EVIDENCE: The home had a complaints procedure and copies were available to people who used the service and their relatives. A copy of the procedure was also included in the service user guide. The procedure gave people appropriate information on how to raise their concerns and complaints and how these matters would be dealt with. People who lived at the home and who could express their views told us that they were aware of the complaints procedure. However, they said that they would, in the first place, make their concerns known to senior staff, who they were confident, would address them appropriately. The manager had stated in the ‘Annual Quality Assurance Assessment’ (AQAA) that was submitted to us before this inspection, that the home had received 13 complaints in the previous twelve months. We checked the complaints record and found that the home had received 11 complaints and three adult safeguarding referrals. The complaints had been investigated and concluded. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 16 The manager confirmed that she had upheld all the complaints. However, there was not always sufficient evidence that the complaints investigations were well recorded and their outcomes appropriately communicated to complainants. There was an adult safeguarding policy to guide staff on the prevention of harm and abuse to people who lived at the home and on the management of any allegations of such practices. There was also information on the safeguarding procedures relating to the local multi-agency safeguarding team. The manager confirmed that the three safeguarding cases had been investigated and also satisfactorily concluded. In discussion, staff stated that they were receiving on-going training on adult safeguarding. Some new members of staff were awaiting training on this subject and the manager confirmed that arrangements had been made for the training to be provided. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived at the home and relatives were satisfied that the accommodation provided was safe, clean, comfortable and pleasant. This helped to maintain and promote the health and wellbeing of people who lived there. EVIDENCE: We checked the premises in the company of senior staff. The home consisted of two separate buildings; Solway and Wentworth. Both buildings comprised of two storeys and had appropriate wheelchair access to them. One building (Wentworth) was used to accommodate people with dementia and the other larger building was for older people who required care mainly because of their physical conditions. Both buildings had passenger lifts to facilitate access to the Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 18 top floors. The Wentworth site was kept secure both internally and externally by use of electronic keypads. This helped to ensure the safety of people who had dementia, by preventing them from wandering out of the building unnoticed. The bedrooms in both buildings were considered as private ‘flats’. They were provided with individual letterboxes and doorbells. This helped to promote personalised and private accommodation. The communal areas in both buildings consisted of dining areas and lounges. There was a sensory room in the Wentworth building for the benefit of people with dementia. The kitchen and laundry facilities were located on the ground floor. The communal areas in both buildings were well decorated, clean and well maintained. The manager explained that there continued to be an ongoing refurbishment programme. The home employs a handyman in order to carry out simple repairs and maintain the décor. We noted that bathrooms and shower facility had been upgraded. We viewed a few bedrooms with the permission of people who lived in them. The rooms were clean and well decorated. However, in some instances, we noted that a few large packs of continent wear were kept on the floor. The manager agreed to move them away and store them more discreetly. The bedrooms were well furnished. A few people had brought in some memorabilia and this helped to personalise their bedrooms. The manager confirmed that the service was making sure that it provided all the furniture that was required. There were garden areas surrounding each building. At the Wentworth site, the home had set up a secure sensory garden for use by people who have dementia. The garden areas at Solway also comprised of raised beds to help people participate in gardening activities. People who lived at the home and relatives said that they were satisfied with the accommodation provided. They felt that the home was very ‘pleasant, safe and comfortable’. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although, the care staffing level was improving, the deployment of staff did not always ensure consistency of care to people who lived at the home, in particular, those who suffer from dementia. This could affect both the quality of care being provided and the welfare of people who used the service. EVIDENCE: The home was organised in two separate units. One of them (Wentworth) was for people who had dementia and the other (Solway) for older people who needed care mostly because of their physical conditions. The unit for dementia could accommodate up to 25 places and the other unit was for 45 places. At the time of our visit, there were 23 people in the Wentworth unit, for dementia and 38 people in Solway. We looked at the duty rota. It showed that at the Wentworth unit, there were on the morning shift, four care assistants, besides a team leader and three care assistants and one team leader in the afternoon. Staff told us that team leaders were responsible for the shift and did medicines. They were mostly busy with these duties. Two waking care assistants were scheduled to work at night. On the Solway unit, there were five care assistants and one team leader throughout the day. Three care assistants were scheduled to work at night. There was an activities coClifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 20 ordinator who worked four hours a day and she divided her time between the two units. On the day of our visit, we met a number of volunteers who were preparing for an ‘Autumn Fair’ and were busy interacting with people who lived at the Solway unit and some relatives. We noted that the staffing level was not calculated on dependency needs of people using the service, in particular those who suffer from dementia and on the lay out of the buildings. In discussion, the manager stated that the staffing level had improved since the last inspection. This was evident in the Solway unit. On the day of our visit, we noted that some people in the Wentworth unit were often left on their own in the main lounge. People who lived at the home told us that although the staffing level was improving, they felt it was taking a long time for the home to get the required level of staff. In discussion, the manager stated that the home was recruiting more care staff and would address these areas of concern. However, people who used the service said that staff were ‘good at their job’ and ‘very caring’. We looked at the files of three care workers who had been recruited to work at the home since the last inspection. They included all the pre-employment checks, including appropriate disclosures. The files also indicated that they had been offered the appropriate induction and initial training. This helped to ensure the safety and wellbeing of people who used the service. It also ensured that new staff were able to start providing the required care to people. In discussion, staff told us that they had received training on a number of topics. These included health and safety and moving and handling, fire training, first aid, dementia care, adult safeguarding and medicines administration. The manager stated that she was planning staff training on the mental capacity act and the deprivation of liberty safeguards. Information from the ‘Annual Quality Assurance Assessment’ (AQAA) indicated that 23 out of 45 permanent care workers at the home had achieved their ‘National Vocational Qualification’ (NVQ) level 2 in care. The manager told us that she was planning to get more care staff through this training. We also noted that the current staff team did not reflect well the diversity of the local population. This may affect the ability of the service to appropriately meet the needs of people from diverse backgrounds. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was appropriately organised and managed. There were quality monitoring systems in place to help staff deliver an appropriate service. These helped to promote the health, safety and welfare of people who lived at the home. EVIDENCE: There have been some changes in management staff in the last twelve months. An acting manager was in post for a period of time and a manager had been appointed since April 2009, but she resigned her post. A new manager has been appointed. She has experience in working with older people Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 22 and in managing a care home. She is also an ‘NVQ’ assessor. She stated that she was undertaking the ‘Leadership Management Course’ and that she was applying for registration with this Commission. Staff and people who lived at the home told us that the new manager was ‘approachable, friendly and very committed to her work’. They felt that she was developing a good rapport with them. Relatives and volunteers also told us that they were satisfied with the work of the new manager. Staff told us that they felt well supported in their work and that the manager was ‘always ready to help with any issues they had’ and that she was honest and open’ in the way she dealt with them. Staff also confirmed that they were being provided with regular supervision. The manager explained that staff had use of various quality monitoring tools to help improve the service. These included the use of ‘Residents Meetings’ to obtain feedback about the running of the home and about the care being provided. Staff were also using regular satisfaction surveys by people who used the service and relatives. The manager told us that staff were also using various audit tools, both for the home and the Company. One audit which was carried out by the company was the ‘Operating Excellence Audit’ and this was a comprehensive tool covering care standards and all aspects of the home management. Staff told us that they carried out audits of health and safety, medicines management and care planning. The registered provider was also conducting appropriate monthly unannounced visits to the home. Reports of these visits showed that they were also used to improve the quality of the service. Staff had access to a comprehensive list of relevant policies and procedures on care practices to guide them in their tasks. The manager had submitted the home’s ‘Annual Quality Assurance Assessment’ document to us prior to our visit. It showed that appliances, utilities and equipment used at the home were appropriately serviced and maintained. Appropriate risk assessments and health and safety measures, including infection control and fire precautions were in place. These helped to maintain the health, safety and wellbeing of people who lived at the home. Arrangements were in place to support people living at the home with the management of their personal monies. All financial transactions undertaken on behalf of people concerned were recorded, witnessed and signed for and receipts were kept. We noted that people could access their money at all times. Regular audits of these accounts were undertaken and they showed that they were correct. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? None 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 OP27 Regulation 18 Requirement The provider must further review and improve the deployment of care staff at the home, particularly in the unit for people who suffer from dementia. This will help to ensure that all identified needs of people living at the home are appropriately met. Timescale for action 29/01/10 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 OP7 OP7 Good Practice Recommendations All aspects of care documentation should be appropriately completed in a timely manner. This will help staff improve their care planning practice. Actions that are laid out in care plans, in order to meet identified needs of people, should be more specific and relevant. This will help care staff in delivering the DS0000003101.V378377.R01.S.doc Version 5.3 Page 25 Clifton Meadows 3. OP7 4. OP7 5. 6. 7. OP16 OP19 OP29 appropriate care. Staff should record the methods by which they undertake care plans reviews and should be able to justify the outcomes of such reviews. This will help in ensuring the appropriate evaluation of care provided. The records of medicines received at the home should be further improved to indicate the ‘carried forward’ figure of medicines for individuals concerned. This will help in ensuring an appropriate stock control of medicines at the home. All complaints investigations should be properly recorded and outcomes of complaints should be communicated to complainants, with records kept. Packs of continence wear and other care products should be appropriately stored and not in people’s bedrooms. This will help to make their rooms safer and more pleasant. Efforts should be made to ensure that the care team is more appropriately comprised of people of diverse backgrounds and in particular, the male gender. This will help in meeting the cultural and specialised needs that people using the service may have. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 27 Clifton Meadows DS0000003101.V378377.R01.S.doc Version 5.3 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!