Inspection on 28/11/05 for Clapham Lodge

This inspection was carried out on 28th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clapham Lodge 08/11/07

Clapham Lodge 19/03/07

Clapham Lodge 23/06/05

Clapham Lodge 08/11/04

Clapham Lodge 20/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clapham Lodge Woodland Close Clapham Village Worthing West Sussex BN13 3XR Lead Inspector Mr D Bannier Unannounced Inspection 28th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 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. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clapham Lodge Address Woodland Close Clapham Village Worthing West Sussex BN13 3XR 01903 871326 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) Clapham Lodge Limited Miss Ann Marie Burch Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Clapham Lodge is a care home registered to accommodate up to 26 residents in the category of OP (Older Persons). Clapham Lodge is a large detached property, located in a rural setting, in Clapham Village, north of Angmering. Accommodation is provided in single bedrooms located on the ground and first floors. Some of the accommodation consists of a bedroom, a sitting room/kitchenette and a bathroom. The communal areas, including a dining room and a lounge area are located on the ground floor. A vertical lift provides access to all floors. An extensive garden which includes lawns and flower borders is available to residents. The service is privately owned by Clapham Lodge Ltd, and the registered Manager is Miss Ann Burch. The responsible person acting on behalf of the company is Mr Paul Renshaw. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 10am. It took place over three hours. The inspector spoke separately to four residents and to two staff who were on duty. The deputy manager showed the inspector around the care home. Some records were also examined. The Commission has also received a complaint about this care home since the last inspection. Mr Renshaw was asked to conduct an investigation into the matters raised. The Commission has arranged a meeting between Mr Renshaw and the complainant to discuss the outcome of his investigation. The Commission has also written to each party to confirm the outcome and the action to be taken to address those parts of the complaint that have been upheld. What the service does well: What has improved since the last inspection? There was one requirement identified during the last inspection. This was to cover a radiator in a lounge to ensure residents are not at risk of scalding themselves. As the registered provider intends to change the use of this room this work has not been completed. The provider is advised to take appropriate action to ensure residents are protected from scalding themselves. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 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 Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards in this section were assessed on this occasion. Key standards had been fully met at the last inspection. EVIDENCE: Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 and 10 A care plan setting out the identified needs of each resident has been drawn up. However, it was not clear how each resident’s needs would be met. It was also not clear if residents, or their relatives are consulted when care plans are drawn up and reviewed. Appropriate action has been taken to ensure residents’ health care needs are fully met. It is the policy of this home for senior staff to be responsible for residents’ medication. There was no evidence to confirm that residents had been consulted or residents’ wishes have been taken into account. Residents feel they are treated with respect and their right to privacy has been upheld. EVIDENCE: The inspector read three care plans. Care plans were informative and included information about the assessed needs of each resident. However, they did not include appropriate information for staff to follow with regard to how identified Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 10 needs should be met. There was no evidence to confirm that residents or their families had been consulted when care plans had been drawn up or amended. It was therefore not possible to determine if staff is providing care on a consistent basis and in accordance with the wishes of individual residents. A record has been kept of visits by district nurses or GPs to provide treatment to individual residents. Residents told the inspector that staff will arrange such visits if requested to do so or if the resident requires treatment in order meet health care needs. Otherwise a local GP will visit the care home on a fortnightly basis. Ms Burch told the inspector that currently no residents are responsible for their own medication. As there was no evidence of residents being consulted with regard to the care provided, the inspector was unable to determine if residents had been asked if they wished to look after their own medicine. The inspector looked at records of medicines. These have been well maintained and kept up to date to ensure medicines have been stored and administered safely to residents. The deputy manager explained to the inspector that medicines are dispensed from marked containers directly to residents. This means that the risk of residents being given the wrong medication is reduced. Residents spoken to expressed their satisfaction with the care provided. One resident told the inspector that “Staff are fantastic; they are marvellous!” They also confirmed that staff treat them with respect and maintain their dignity at all times. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards in this section were assessed on this occasion. Key standards had been fully met at the last inspection. EVIDENCE: Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The registered provider has taken appropriate action to ensure residents and their families are confident their complaints will be listened to, taken seriously and acted upon. Other key standards had been fully met at the last inspection. EVIDENCE: Residents spoken said that if they needed to make a complaint they would take it up with the manager. Although no residents spoken to have found it necessary to make a complaint, they told the inspector that they felt confident that the manager would be able sort out any concern they may have. A written complaint procedure was on display in the front hallway of the care home. The inspector also saw that copies of the care home’s Statement of Purpose were available in residents’ bedrooms. A copy of the home’s complaint procedure has also been included in this document. This includes information for residents with regard to whom they should make their complaint and how long it will take before they should expect to receive a response to their concerns. The inspector was told that the care home has kept a record of complaints received. However, the record was not available, as Mr Renshaw had taken it to record a complaint that the care home had recently received. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 A radiator that had been identified in the last inspection had not yet been covered to ensure residents are not risk of scalding themselves Other key standards had been fully met at the last inspection. EVIDENCE: The inspector viewed the small lounge on the ground floor and saw that the radiator had not been covered. Ms Burch informed the inspector that Mr Renshaw intends to change this room in the near future. The manager explained that this is due to residents no longer using this room. The inspector advised Ms Burch that, despite this, the registered person is required to ensure all areas of the care home are safe for residents to use. It is recommended that the registered provider take interim measures to reduce the risk of residents scalding themselves until work commences on changing the use of this room. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Staff have been provided, whose numbers and skills mix are appropriate to the current needs of residents accommodated. The home’s recruitment policy and practices needs improvement to ensure the protection of residents. Staff has been provided with training to ensure they are competent to provide for residents’ needs. Other key standards had been fully met at the last inspection. EVIDENCE: The inspector met two staff that was on duty at the time of the inspection. As the deputy manager was one of these staff, she asked another member of staff to come into work. This meant she could assist the inspector with his enquiries. The inspector looked at the rota that showed that there are two members of care staff on duty throughout the day. There are also two awake members of staff during the night. In addition there is a member of the domestic staff to keep the care home clean, and also a member of the catering staff to prepare meals for residents. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 15 The residents told the inspector that they felt well cared for. One resident said, “Staff are friendly and kind to us.” The inspector was told that two new members of staff have been employed to work in the care home since the last inspection. He was also informed that the registered provider had applied for criminal record checks for each member of staff. They had started to work at the care home even though these checks have not been returned. The inspector was advised that it was the registered provider’s understanding that checks obtained by their previous employer were still valid. The registered provider is advised that criminal record checks are not transferable. The Commission expects that the registered provider apply for such checks for all new staff before they commence work in the care home. In the meantime the registered provider should obtain a self-declaration from each member of staff confirming they do not have criminal records. The member of staff concerned should not be allowed to work unless they are supervised by an experienced member of staff who has a current criminal records check. In addition, they should not be allowed to escort a resident outside of the care home unless an experienced member of staff accompanies them. This should ensure vulnerable elderly residents are protected from possible abuse. The inspector spoke to several staff that was on duty. The staff clearly understood the needs of the residents who were being accommodated and they how they were expected to meet them. Records seen showed that each member of staff had been provided with appropriate training, including induction training. Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 36 The registered provider has taken appropriate action to ensure residents’ finances have been safeguarded. The registered manager has ensured all staff has been appropriately supervised. Other key standards had been fully met at the last inspection. EVIDENCE: A representative of the registered provider informed the inspector that it is not the policy of the care home to handle the financial affairs of residents accommodated. It is expected that either the resident of their relatives take responsibility for this. One resident told the inspector that their son in law pays Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 17 the bills whilst another resident explained that they deal with their finances themselves. Records seen showed that care staff is supervised regularly by someone senior to them at least every six weeks. Supervision sessions include identifying training needs and supporting staff to help them ensure the aims and objectives of the care home is put into practice. Staff spoken to confirmed that supervision takes place and is supportive. Staff spoken to clearly understood what was expected of them whilst working at this care home. Residents were very complimentary about the staff. One resident said, “Staff are very helpful.” Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x 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 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x x x x x x x 2 x STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 3 x x Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 15(1) Requirement Timescale for action 02/01/06 2 OP7 15(1) 3 OP29 19(1)(b) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible are eliminated. In this case, the registered person shall take appropriate action to ensure service users are not at risk of scalding themselves on excessively hot surface temperatures of a radiator identified in this report. (Previous timescales of 30.09.04, 31.12.04 and 30.09.05 not met) The registered person should 02/01/06 amend service user plans to ensure they include information with regard to how service users’ needs in respect of their health and welfare are to be met. The registered person shall not 02/01/06 employ a person to work at the care home unless subject to paragraph (6), (8) and (9), he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. This refers to the obtaining of a DS0000014456.V260654.R01.S.doc Version 5.0 Clapham Lodge Page 20 new criminal records check before the person concerned commences work at the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clapham Lodge DS0000014456.V260654.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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