Inspection on 03/06/08 for Clore Manor

This is the latest available inspection report for this service, carried out on 3rd June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clore Manor 24/07/06

Clore Manor 24/01/06

Clore Manor 14/04/05

Clore Manor 12/10/04

Clore Manor 18/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Clore Manor 160-162 Great North Way Hendon London NW4 1EH Lead Inspector Duncan Paterson Key Unannounced Inspection 3 & 6 June 2008 09:30 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 Clore Manor DS0000010423.V364592.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. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clore Manor Address 160-162 Great North Way Hendon London NW4 1EH 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) 020 8203 1511 020 8202 6426 Jewish Care Manager post vacant Care Home 72 Category(ies) of Dementia - over 65 years of age (72), Old age, registration, with number not falling within any other category (72) of places Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th June 2007 Brief Description of the Service: Clore Manor is registered to provide care for seventy-two elderly people some of whom have problems associated with dementia. The home is operated by Jewish Care and therefore observes a lifestyle promoting Jewish beliefs and culture. The home is located off the busy Great North Way in Hendon, on the edge of a residential area. It is a short drive to local shops and businesses and Brent Cross shopping centre. The stated purpose of care practice is to provide a homely, relaxed and safe environment for the residents, with an emphasis on individual differences. The aim is to treat residents with dignity and respect, where they can live as individuals leading as full and active lives as their physical and emotional condition will allow. The main building is on three floors. The two extensions that have been added over the years are on two levels at each end of the original building. The home has been effectively divided into three units. One of these, accommodating fourteen service users is designated as a dementia care unit. All service users bedrooms have en suite facilities, with a toilet and bath or shower. Each of the three units has communal sitting and dining space. There is a lift to assist people with mobility problems to gain access to the upper floors. The current scale of charges range from £709 to £758 per week. A copy of this report is available on the CSCI website or/and from the home. Clore Manor DS0000010423.V364592.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 the people who use this service experience good quality outcomes. This key inspection took place on 3 and 6 June 2008. The inspection involved time at the home talking with residents, staff, relatives, visiting professionals and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. Three resident’s care arrangements were looked at in each of the home’s three units. The inspection also involved the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. What the service does well: What has improved since the last inspection? The requirements given at the last key inspection of 4 June 2007 have been complied with. The new manager has now been in post for almost one year and feedback received at this inspection, as well as direct observation, is that Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 6 the new manager has quickly been able to provide effective leadership for the staff team and to improve the operation of the home. 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 summary of this inspection report can be made available in other formats on request. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 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 Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 134&5 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a detailed assessment process with a number of built in safeguards to ensure that admission decisions are considered. There is a range of information available about the service. EVIDENCE: I was shown the home’s statement of purpose. It is a clearly written document which clearly sets out the services provided and the aims and objectives. It provides details about the home and staff and is available for people within the hallway entry area along with other information and photographic displays about the service. The manager explained to me the assessment and admissions process for the service. This involves the Jewish Care social work team who assess all prospective residents. That is followed by staff from the home assessing prospective residents, a day’s trial visit and the Jewish Care panel. The manager said that the trial visit allowed more assessment time as well as the Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 9 opportunity for people to sample life at the home first. The manager felt that this allowed good quality assessments to be made before people move into the home. The home is divided into three units. There is a larger main unit as well as two smaller units, one of which is a specialist dementia care unit where there are higher ratios of staff. I spoke to residents and relatives in each of the three units. Many positive comments were received. One resident told me that, “staff are good and kind”. Another resident told me that, “staff are very helpful and good and they do their best”. A relative said that the home was, “excellent”. However, there were some concerns raised with me. Primarily these were about the impact some people with dementia have on the atmosphere and on others. This is discussed in detail in the next section. The AQAA returned to us before the inspection set out the equality and diversity initiatives that had been taken. These included adaptations to the environment such as introduction of automatic doors and refurbished more accessible bathrooms. I was shown these when touring the building with the manager. Quite rightly, emphasis is placed on the provision of a service based on Jewish religion and culture. Residents to whom I spoke told me that living in such a home was important to them. Intermediate care is not provided at this service. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 10 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 10 & 11 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been a great deal of input, at management and staff level, to develop the dementia care services and improve the quality of life for residents. There is a positive culture of care and sensitivity amongst the manager and staff. EVIDENCE: I inspected three care plans in each of the three units, spoke to staff, residents, relatives and visiting professionals and spent time observing. I also had conversations with the manager and one of the care managers to discuss the aims for the service and arising issues. The manager told me about Jewish Care’s approach to dementia care and the dementia care initiatives the home was following. I was told that within the organisation there is a dementia care manager who has the role to develop the dementia care services overall. For this home it involves visiting the home every 2-3 months to provide training and provide input for staff on specific Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 11 care planning issues. Within the home and the organisation there are a number of dementia care champions who meet regularly. There was also a specific dementia care project run at the home. This was the “Music for Life” project which involved eight residents and five staff over a 13 week period. Some of the staff I spoke with confirmed that they had been involved in this project. There is programme of person centred training for staff and again staff told me that they had received this training and that it was helpful. I saw some very positive examples of staff interaction with residents. For example, in the dementia unit I saw staff sitting talking on an individual basis with residents and being very kind, tactile and reassuring in their approach. Similarly, in the main unit I saw staff taking time out from day-to-day tasks to sit and talk with residents. I also saw a number of visitors and volunteers who were in and out of the home all the time spending time with the residents or running sessions such as a music session. I saw that there was an open, friendly, caring culture at the home. Having said that, some people within all three groups of staff, relatives and residents raised the issue with me of challenging behaviour and it’s management. There were a small number of residents that, on occasions, had behaviour associated with dementia, which involved them in shouting out or becoming distressed. I could see that there was an impact on others in the lounge including residents and staff. Some of the residents I spoke with said that they were not happy about it but they would move to their bedroom or another part of the home if it became too much. Some relatives also spoke to me about the impact the behaviour had on their relative and how it was unsettling for them. A number of the staff felt that the management of challenging behaviour was one of the biggest challenges they were facing. However, each member of staff I spoke to about this told me that there procedures and methods to follow when working with residents who may be distressed and challenging. I saw evidence of this work during the inspection such as staff spending time on a one-to-one basis with residents or providing a diversion activity such as knitting. One member of staff told me that it was hard work providing intense individual work with residents whilst at the same time providing a service to everyone. She felt that inevitably the more independent residents may suffer. I found that there had been considerable thought and actions put into addressing this issue. The care manager I spoke to told me of the techniques followed by staff to address individual residents needs including reviews of care plans, in house training for staff, team discussions and use of such techniques such as dementia care mapping. The assessment information had been extended to give a more person centred section including residents’ likes and dislikes and a summary of their care needs. The manager also told me about a Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 12 recent rearrangement of the layout of the lounge which had been an initiative to address people’s privacy and quality of life whilst spending time in the main lounge. Staff confirmed that this had happened and that it had had a beneficial effect. Similarly, the manager told me about another initiative where a daily team meeting for staff had been introduced. The aim of this was to focus on the care plan rather than the tasks for the day and to use the opportunity to problem solve. I spoke to staff about this. They told me that they used the opportunity to talk about the shift and what happened and how best to care for individuals. This inspection has identified that there is a fertile environment for providing good quality dementia care as well as a willingness and ability from the management and staff team to address issues and develop the service. A recommendation is given for there to be a continuation of ways of addressing challenging behaviour to ensure that residents’ quality of life is maximised. From my inspection of care plans I identified that the objectives tended to be task focused rather than person centred. There were person centred aspects to the care plans but more could be provided in terms of what actions staff were taking to address needs. For example, when I discussed care provision with staff I found that staff were clear about their role and the reassuring and diversion techniques being followed. However, when I looked at the care plan these details were not present. Overall, the care plans I saw were detailed and effective. I could see that they provided a reliable record of care provided as well as guidance for staff. However, I noted that there were some gaps in care planning records such as a lack of recording of individual weights for people in the dementia unit. What is required is some attention to detail to ensure that records are kept up-todate. A recommendation is given about this. The majority of residents are registered with the same GP who provides a weekly surgery. I was able to speak with the GP during the inspection. She said that she had been providing a service to the home for 4-5 years and that there had been an improvement during that time. She said that this was down to the two care managers and staff being organised about the referrals to her. Also, that staff were more confident about dementia care and therefore not making inappropriate referrals to her. She also felt that staff were more understanding about medication and not asking for medication to calm behaviour. She said that medication for residents was being reviewed every six months. I also spoke with a visiting community nurse who told me that she felt there was a very high standard of care provided to residents. She said that she had seen nine residents that day for a variety of issues including dressings, Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 13 catheter care and injections. She said that she visited twice a week and found it a pleasant, welcoming care home. I looked at the medication storage arrangements and records in each of the three units. Mobile medication cabinets are used which are stored in the treatment room at the front of the home when not in use. The treatment room is cool and also contains a fridge and separate storage for controlled drugs. The team leaders take the lead for administering medication as well as recording the receipt in of medication. The care managers audit the process every month. The Boots blister pack system is used. I noted that the records were clear with staff knowledgeable about medication. I was shown the records for controlled drugs and I saw that these were clear and that they had been signed by two staff when administered. I saw medication training records later when I sampled staff training records. I saw details about arrangements after death on the care plans that I looked at. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 14 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): 12 13 14 & 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a wide variety of activities and events provided for residents. These are developing as residents needs change. The support of the local Jewish community and extensive use of volunteers means that residents have their Jewish identity positively upheld. EVIDENCE: I identified that there is a lot of activity at this home. There are two activity organisers, a holistic therapist and 70 volunteers. There are also many relatives who visit frequently and take an active part in helping out. During the visit I met a volunteer physiotherapist as well as volunteers who were running music sessions and others who spent time chatting with residents. I was told that school pupils from local schools visit and that the home is very much part of the Jewish community. I saw that there were preparations being made for a forthcoming Jewish festival whilst I was there. The relatives are also active in fund raising with money having been raised for equipment such as a new flat screen TV as well as for other costlier building projects. One of the activity organisers was sick during the inspection and another on leave which meant that I was unable to obtain the fine detail of the work they Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 15 were doing. However, I was able to speak to one of the organisers on the telephone. She told me that there were a variety of activities including the marking and celebration of Jewish life with assistance from Jewish volunteers as well as the observance of Jewish holidays and holy days. There were fixed activities such as trips out each week as well as entertainment every Sunday. She said that there was now a lot of one-to-one work which was what people were wanting and that she could support staff in her provision of activities. For example, by working on a one-to-one basis with people who may be distressed, confused or challenging. In addition, she said that they take themes such as the Ascot races and Wimbledon and organised events at the home using images and props from these events. I was able to confirm all these events were taking place either from discussions with residents, relatives and staff as well as by viewing photographs in the entrance hallway to the home. The activities organiser also told me that she has been involved in residents meetings and that she has used a questionnaire to obtain feedback from residents about activities. I observed lunch being served in the main unit as well as breakfast in the extension unit and afternoon tea in the dementia unit. I could see that care had been taken to make sure that residents enjoyed meal times. I could also see that important rituals were maintained such as laying the table attractively before meals, helping residents to eat and allowing residents to sit together. For example, I observed staff setting the table for afternoon tea in the dementia unit, assisting residents to sit at the table and then spend time sitting with residents whilst they had their tea and cake. Breakfast in the extension unit was also calmly and carefully managed so that residents enjoyed peace and quiet as well as some attentive service from staff. There was a choice for the main meal of the day and the meal served efficiently with residents helped to eat if needed. The catering staff brought the food to the main lounge in a heated trolley and care staff served. I spoke to residents about the food. The majority of residents told me that they liked the food although some expressed reservations. A typical comment was that, “you can’t expect too much”. Such comments may indicate the need for more work to be done on obtaining residents’ views about the food and other aspects of the service. I identified in this inspection that more quality assurance work was needed to gather resident’s views. This is one area that can be covered in that process. More detail on this is provided later in the report. I was shown a Barnet Council food safety certificate dated 30 April 2008 from the “Scores on the Doors” scheme. Five stars had been awarded which is the highest amount of stars that can be awarded. This scheme covers food safety and hygiene and indicates that a high standard of food handling is in operation. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 16 The catering and domestic tasks have been contracted out by Jewish Care to an independent company. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 17 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 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints procedures are clear and accessible to people using the service. Safeguarding arrangements are suitable with a clear policy and procedure and training now having been extended to all staff. EVIDENCE: I was shown the home’s complaints records. There have been three recorded complaints since the last key inspection on 4 June 2007. The records provided evidence that the matters had been properly followed up and investigated. I identified that the safeguarding arrangements are suitable. There is a safeguarding policy and procedure which describes types of abuse as well as detailing what action needs to be taken in the event of an incident or allegation of abuse. This includes referral to the local authority. I saw from the training records that staff had been receiving safeguarding training with a further mopping up training sessions scheduled for the week after the inspection. There was an outstanding requirement about the provision of such training. However, with the final staff training session to be delivered immediately following the inspection the requirement has been complied with. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 18 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 20 21 22 23 24 25 & 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. This is a large home that is pleasant, homely and welcoming. There are some attractive features and work has been completed to enhance the facilities for the benefit of residents. EVIDENCE: This is a large care home with bedrooms on the ground, first and second floors. The home has been extended over time and is now arranged into three units, each with their own communal areas. There is a service area on the ground floor including the kitchen and laundry areas. I toured the building with the manager. I was shown bedrooms which were currently being refurbished and I was told that there is an improvement plan for the physical standards at the service. The manager said that he had had regular meetings with the Jewish Care property services since starting work at Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 19 the home. In addition, the money relatives raised was sometimes used for various building projects. The home is pleasant and welcoming. Although the large main unit lounge can be busy there is a second smaller lounge that can be used. However, this lounge is not used very much by residents. The two smaller units only have one lounge area each but residents can use other parts of the home for activities and if desired. When I was in the extension unit residents told me that the room had recently been rearranged. Staff confirmed this as well as visiting relatives. There was some dissatisfaction expressed from residents and relatives to whom I spoke although I could see that there had been discussions with staff and the manager. The manager told me that there were ongoing discussions. The reason for the rearrangement was to try to use the room more flexibly as the room served both as a lounge and a dining area. One of the residents told me that there had not been any consultation with them about the rearrangement. Again, it will be productive to include this sort of thing in quality assurance initiative of gaining feedback from residents. I received feedback from some residents that there were delays in getting help in the morning due to a lack of wheelchairs. I discussed this and the overall availability of adaptations with staff and the manager. I found that the issues were complex with some problems caused through staff not always replacing the footplates on wheelchairs and some staff not being confident about using new hoists. Some staff felt that agency and temporary staff did not always carry out this aspect of the work as thoroughly as permanent staff. The manager told me that the wheelchairs in use were serviced regularly by the maintenance officer at the home. However, given the comments received from residents and relatives a recommendation is given that there is a review of the wheelchairs in use and that records are kept of the servicing of wheelchairs. I visited the laundry during the inspection. This service, along with the overall catering and housekeeping arrangements has been contracted out to an independent provider. I saw that the laundry was well equipped with three washing machines and three dryers. However, one of the washing machines was not working which could place a strain on the facilities. A recommendation is given that the washing machine is repaired or replaced. I spoke with a laundry worker who told me that there were usually two staff on duty working between 6.30am and 2pm every day. I saw that the laundry had been efficiently arranged. I was not told of any problems with the laundry by the people to whom I spoke. I noticed that there were a number of residents who clearly took a great deal of pride in their appearance with their clothes Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 20 colour co-ordinated, smart and neat. These residents told me that they had no trouble getting help from the staff to maintain their standards. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 21 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 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recruitment is carried out effectively with the required checks having been obtained. Relevant training is provided for staff. The recent recruitment of permanent staff should help provide a more consistent workforce for the benefit of residents. EVIDENCE: This home arranges staff cover through a system of a number of staff teams working 12 hour shifts. Each team has a team leader. They work for three to four days at a time and are then replaced by another team working a similar pattern. In addition, there are two care managers at the home as well as the manager. This arrangement is not without its problems as staff working long hours can get tired and make mistakes. However, when I spoke with staff they did not tell me that the 12 hour shifts were a problem. They stressed the days off they got in between shifts and reported that the difficulties they faced were not long hours but caring for people with challenging behaviour and working with temporary rather than permanent staff. I was able to see from observations and discussions with staff that there were a number of agency staff working at the home. I was told by the manager Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 22 that there had been some recent recruitment and that eight vacancies had been filled. This should result in a more consistent service for residents. In order to assess the recruitment arrangements I inspected the files for four recently recruited staff. I found that the recruitment had been carried out thoroughly and that the required information including CRB checks had been obtained. I then went through the training arrangements with the manager. I was shown a training matrix, computer training records and extracts from the training budget. I then looked at the staff files for seven staff in order to assess what training they had received. Three of the staff were people to whom I has spoken (and asked questions about training) during the inspection. I could see from the training records that there was a wide variety of training available for care staff. This was mainly provided by the Jewish Care training department but with some external training such as food hygiene from the independent provider running the home’s catering service. The manager was able to show me details from his training budget which confirmed that staff were to attend relevant training throughout the year. In my discussions with staff I was able to hear from staff what training they had attended. Many staff, for example, confirmed to me that they had received the person centred care training. Some of the staff confirmed that they were to attend the forthcoming safeguarding training. The computer records also covered staff who had completed or were carrying out NVQ training. The home’s AQAA reported that 76 of the staff were working towards NVQ Level 2 or above. All the staff files that I looked at had records of training received. Staff had typically completed a range of training including dementia care and induction. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 23 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 32 33 35 36 37 & 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is experienced and provides strong leadership and guidance for staff. The development of the quality assurance arrangements will provide residents with more opportunities to provide feedback about the service. EVIDENCE: The manager of the home is an experienced care home manager. I was told by many of the staff that they liked the manager and the work of the management team finding them all approachable and helpful. One member of staff, for example, said that she had raised some issues with the manager and found that they had been listened to and resolved which she said was helpful. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 24 I observed the manager over the two days of the inspection in his interactions with staff, residents, relatives and professionals. He was approachable with all and he was often walking around the home taking time out to talk with residents or staff and take action to deal with arising matters. He was also knowledgeable about what was going on in the home particularly care provision. The manager is not yet registered. There was some confusion about whether an application had been made to CSCI. After enquiries it was established that the application had not been but the manager has undertaken to make the application as soon as possible. I discussed the home’s quality assurance initiatives with the manager. There is a policy which sets out a number of initiatives including a monthly audit by managers, questionnaires, dementia care mapping, an external audit, a six monthly health and safety manager inspection, and staff and residents meetings. I was shown recent reports which had been completed by the Jewish Care’s quality assurance team. However, these referred to maintenance and health and safety matters in the main rather than to care issues. The monthly audit was completed by the manager to his line manager. The manager said that there had been work completed by the activities manager based on Jewish Care’s “listening manager”. This involved the generation of feedback from residents. However, the manager also said that questionnaires for residents had not been done. I was not able to conclude, therefore, that sufficient work had been completed to obtain feedback from residents and relatives about the service. Such feedback will be useful as it can provide details of areas where there may be shortfalls or where areas can be developed. This inspection has found that such areas may include the food provision, complaints and the rearrangement of furniture in the lounge areas. As there is a great deal of involvement from relatives, volunteers and others already, as well as residents and relatives meetings, obtaining feedback should be relatively straightforward. A requirement is given that obtaining feedback from residents and others is carried out I looked at the safeguarding arrangements for residents money with the manager. I was shown the computer records that are held and I was able to cross check two with the paper records. The manager said that none of the residents look after their own money. Relatives do that with two exceptions where local authorities take the lead providing the home with the resident’s personal allowance. The money held for residents is in a general account with surplus over £200 going into an interest bearing account. I discussed staff supervision arrangements with staff to whom I spoke. I also looked at a sample of the supervision records. Supervision is divided as follows. The manager supervises the care managers who in turn supervise team leaders who then supervise care staff. Staff, in the main, confirmed that Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 25 they had received staff supervision on a regular basis. From the records I saw that the majority of staff had received supervision on a regular basis. There were detailed supervision records. One person who had just started work had not received formal supervision yet. Another longer serving member of staff had not received supervision and another longer serving member of staff had only one record of supervision. It is important that staff received regular supervision so that staff receive regular guidance and encouragement as well as there being a check on staff competence. I was shown records for the servicing and maintenance of equipment at the home as well as such records as gas and electricity certificates. The work to complete all of this has been contracted out to the Kier organisation. They provide a central file in which these certificates and checks are kept. I was shown these records as well as back up certificates kept on computer where necessary. I could see that a thorough approach had been taken to health and safety maters and the need to maintain the home and service equipment on a regular basis. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 26 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 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 3 2 x 3 2 3 3 Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 27 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 OP33 Regulation 24 Requirement Feedback from residents, relatives and others must be obtained as part of the quality assurance initiatives in order to assess whether the aims and objectives are being. All staff must receive supervision on a regular basis. Timescale for action 01/10/08 2 OP36 18(2) 01/09/08 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 5 Refer to Standard OP7 OP7 OP7 OP22 OP26 Good Practice Recommendations Continue ways of addressing challenging behaviour to ensure that residents’ quality of life is maximised. Continue to develop care plans with a person centred focus. Ensure that care plan entries are accurately maintained. Review the wheelchairs in use and that records are kept of the wheelchair servicing. Repair or replace the defective washing machine. Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Clore Manor DS0000010423.V364592.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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