Inspection on 08/11/07 for Clapham Lodge

This inspection was carried out on 8th November 2007.

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 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

Clapham Lodge 19/03/07

Clapham Lodge 28/11/05

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 Mrs J Hough Unannounced Inspection 8th November 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clapham Lodge DS0000014456.V349698.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. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 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) claphamlodge@btopenworld.com Clapham Lodge Limited Mrs Christine Helen Woods Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - (OP) The maximum number of service users to be accommodated is 26. Date of last inspection 19th March 2007 Brief Description of the Service: Clapham Lodge is a care home registered to accommodate up to 26 people in the category of OP (Older Persons). Clapham Lodge is a large detached property, located in a rural setting, in Clapham Village. 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. There is an extensive garden that includes lawns and flowers that people can access. The service is privately owned by Clapham Lodge Ltd, and the registered manager is Christine Woods. The responsible person acting on behalf of the company is Ms Genevieve Reed. Current scale of fees is from £400.00 to £750.00 per week. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 8th November 2007 and started at 10:30 hours and finished at 13:30 hours. The evidence contained in this report was gained from a review of the information the provider sent to the Commission of Social Care Inspection (CSCI) that included an Annual Quality Assurance Assessment (AQAA), which had been completed by the manager prior to the visit. Ten surveys from people living in the home and relatives were completed and returned to the Commission and feedback given on surveys is included in this report. The manager was present during the site visit and kindly provided the information required. During the site visit people living in the home and two visitors were spoken to. All areas of the home were seen and documents relating to people’s care, staff files, complaints, and maintenance records were read. What the service does well: People have their needs fully assessed before they move into the home so that they can be confident the home can support them. Staff provide good support to the people maintaining their independence and promoting their privacy and dignity. People are encouraged and supported to maintain contact with their family and friends and visitors are welcomed into the home. People are supported and encouraged to pursue activities of their choice The manager of the home is experienced and qualified and runs the home well. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Clapham Lodge DS0000014456.V349698.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 Clapham Lodge DS0000014456.V349698.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to moving into the home to ensure the home can support them. The home does not provide intermediate care. EVIDENCE: Since the previous inspection there have been no new admissions to the home. The manager completes a comprehensive pre-admission assessment prior to people moving into the home. Areas of assessment include people’s health, personal and social care needs. The home does not provide intermediate care. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are met. People are supported to take their medicines, and medication practices carried out in the home ensure medicines are given, stored and handled safely. People’s rights to privacy are respected and the support they get from staff is given in a way that maintains their dignity. EVIDENCE: Individual care plans are in place that give a detailed account of the health, personal and social care needs of people. People sign their individual care plans where able, to show they have been part of the care planning process. Risk assessments are completed for nutrition, moving and handling, pressure sores and falls. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 10 Separate information in care files showed visits by the GP or other healthcare professionals. The GP visits the home routinely every two weeks, the chiropodist every six weeks and the optician once a year. Advice and support from district nurses is obtained when required. Daily records are kept and monitored by the manager and records updated every two months or when changes occur. The home has a good supply of equipment such as hoists, turntables, and special mattresses. The home has medication policies and procedures in place for receipt, storage, return and administration of medication, which are followed by staff. Medication records were accurate and up to date. People are given the opportunity to take responsibility for their own medication if wished, following a risk assessment to ensure their safety and minimise any risks to them. People spoken to were happy with the care provided and felt the staff were very helpful and friendly, and treated them with respect. Comments included “the staff look after me very well and nothing is too much trouble” and “the staff are not just kind but friendly and courteous”. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a good choice of nourishing food and there are a variety of activities they can participate in. People are able to have visitors at any reasonable times. EVIDENCE: People are encouraged to maintain contact with their family and friends. Visitors spoken to said they were always made welcome by the staff and were able to visit the home at any reasonable time. A plan of activities is displayed in the home and activities include themed buffets, sing-alongs, barbeques, music for health, bingo, raffles and various games. Special events are celebrated such as Christmas, Birthdays etc. The activity organiser arranges activities following discussions with people on what they would like to do. The home has the use of a mini bus and a recent trip to a garden centre took place with further trips to other venues being arranged for the near future. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 12 Food is supplied frozen and pre-packed from an external food company and delivered weekly to the home. Food is then heated and served on the day. Breakfast and tea are prepared and cooked in the home. Catering assistants are employed to cover the kitchen at all times. Menus looked at showed that a well balanced and nourishing diet is on offer. People have a choice of main meal and special diets are catered for. People spoken to were generally happy with the quality of the food and said there was plenty to eat. However, one comment made suggested it would be nice to have freshly prepared and cooked food instead of frozen. People can choose to eat their meals in their room or in the pleasant and spacious dining room. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with information in respect of complaints and understand the process for making a complaint. Staff training on adult protection safeguards the people who live in the home from abuse. EVIDENCE: The home has a written complaints procedure, which is also included in the Service User Guide and kept, in people’s private rooms. There is also a copy of the procedure displayed on the notice board in the hallway of the home. People spoken to, and feedback given on surveys showed people understand the process for making a complaint and said they would speak with the manager direct should they need to complain or raise a concern. The manager confirmed there have been no complaints received for over a year. However, there was no book accessible to staff to record complaints when received The manager said that she would ensure a complaints log was set up and made available for this purpose. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 14 The manager provides Protection of Vulnerable Adults (POVA) training for staff on an annual basis. Staff are aware of the appropriate action should a suspected incident of abuse arise in the home. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service live in a safe, clean and hygienic home. Due to the age and layout of the building the hot water and heating system in the home is not ideal. EVIDENCE: All areas of the home were fresh, clean, comfortable and homely. Improvements and repairs to the environment that were highlighted during the previous inspection had been carried out. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 16 Other improvements include a new carpet in the lounge; new dining chairs and a new call bell system being fitted. People are able to bring personal items into the home and furnish their rooms as they wish. Some areas of the home internally and externally still require further maintenance work. Due to the age and construction of the building the home has three separate heating systems in place, gas central heating, storage heaters and convection heaters. Warning signs have been suitably placed to prompt people of hazards such as steps, low ceilings and slopes. The local fire service visited the home on 21st August 2007 and recommendations made following the visit have been met. The use of door wedges had ceased for propping open people’s bedroom doors although it was noticed that the manager’s office door was wedged open. At present the home has only one bathroom in use for 14 people due to an assisted bathroom being out of action. The home is awaiting parts from the manufacturers in order to repair the bath hoist. Feedback provided on a survey showed that in some areas of the home there is a problem with the hot water system with a lack of constant hot water. It was confirmed that the problem is in the process of being looked at by the providers. Laundry facilities in the home are suitable for the size and number of people. There was no hand washing facilities in the laundry area although these were available close by. The home sends out linen and towels to be laundered and people’s personal washing is done in the home by the care staff. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient and competent staff on duty at all times to ensure people are safe and have the support they need. EVIDENCE: The manager confirmed that two members of staff are on duty throughout the day and night. The manager also works with care staff some mornings providing support. In addition there are domestic and catering staff employed. The manager confirmed that staffing numbers are monitored taking into account the number and dependency levels of the people living in the home. People spoken with said staff are available when needed and are prompt to respond to their calls for assistance. Two staff files were seen to check new members of staff have the appropriate checks carried out prior to employment. All applicants had completed an application form and two written references were obtained from previous employers. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 18 Files showed that a Criminal Records Bureau (CRB) check is completed for all applicants although there was no evidence on files of a Protection of Vulnerable Adults (POVA) check. It was noted that both members of staff started work prior to CRB checks being completed. However it was confirmed by the manager that both members of staff started the induction training and were supervised until checks were confirmed as satisfactory. There is a stable staff team with many of the staff having worked in the home for several years. The home has no vacancies for staff at present and agency staff have not been used for over a year. Four members of the care staff have achieved a National Vocational Qualification (NVQ) in care and two care staff are working towards the qualification. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have confidence in the home as it is run well by an experienced manager. The environment is safe for people and staff as appropriate health and safety practices are carried out. EVIDENCE: The registered manager of the home is experienced and has the necessary skills and qualifications to manage the home. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 20 She has completed the National Vocational Qualification (NVQ 4) in care and the Registered Managers Award. Observations made during the visit showed the manager had an open door style of management welcoming comments and suggestions from people staff and relatives. She also has a close working relationship with staff and supports them by working with them several days a week. People said “the manager is very nice and I can talk to her about anything” and “the manager is very approachable and listens to what I say”. Staff have formal staff supervision every two months from the manager and annual appraisals have commenced for some staff. The manager confirmed that Quality Assurance surveys are sent out to relatives and people living in the home every six to eight months. The last survey completed was in September 2007. People and visitors are also given opportunities to give their views on the home by completing the “talk back” forms that are displayed and available in the entrance hall. Accident and incident forms are recorded and reported as necessary. Maintenance records and fire records seen were up to date. Maintenance records showed that equipment and systems in the home are appropriately serviced and maintained. The Annual Quality Assurance Assessment (AQAA) completed prior to the inspection showed that health and safety policies and procedures are in place and regularly reviewed. Following the inspection carried out by the local fire officer a fire risk assessment for the environment had been completed. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 21 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 3 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 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP16 Good Practice Recommendations Develop a book for recording complaints showing investigations, actions and outcomes that is accessible to staff at all times. Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Office The Oast, Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Clapham Lodge DS0000014456.V349698.R01.S.doc Version 5.2 Page 24 - 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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