Inspection on 11/04/05 for Clare House

This inspection was carried out on 11th April 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

Clare House 30/08/06

Clare House 24/10/05

Clare House 04/11/04

Clare House 10/05/04

Clare House 07/07/03

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clare House Harefield Road Uxbridge Middlesex UB8 1PJ Lead Inspector Clare Henderson Roe Announced 11th & 12th April 2005, 10.00am 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 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. Clare House Version 1.10 Page 3 SERVICE INFORMATION Name of service Clare House Address Harefield Road, Uxbridge, Middlesex UB8 1PJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 272 766 01895 272 896 patsy@leisure4822.freeserve.co.uk BUPA Care Homes Limited Ms Patsy Jackson Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Clare House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. To comply with the Minimum Staffing Notice required by the previous regulator as at 31st March 2002. 2. One named service user with Dementia can be accommodated, as agreed by the NCSC on 21/01/04, for as long as there is no deterioration which affects the well being of other service users. The home must advise the CSCI when the service user no longer resides at the home. 3. Three of the beds currently registered may be used as Palliative Care beds. 4. One named service user under the age of 65 years can be accommodated, as agreed by the Commission for Social Care Inspection, on 24th January 2005, for as long as there is no deterioration which affects the well being of other service users. The home must advise the CSCI when the service user no longer resides at the home. Date of last inspection 04/11/04 Brief Description of the Service: Clare House is a 43-bedded Care Home giving nursing care to frail elderly service users. The purpose built building is situated on a busy thoroughfare leading into Uxbridge town centre. Transport links are by bus. There are 35 single rooms, thirty-four with en suite washbasins and toilets. One single room has a sink. There are four double rooms, all with en suite facilities, and at the time of inspection these had single occupancy. There are five assisted bathrooms and one shower room.The ground and first floors are connected by stairways and a passenger lift. All parts of the home are wheelchair accessible. Wheelchair access is also provided for some of the bedrooms that open onto the patio. Ramps are put in based on family requests. The home provides a large parking area at the front of the building and a garden to the rear. BUPA, a private company, owns the home. It has a Registered Manager, a Deputy Manager, a receptionist, a bursar, registered nurses, care staff, chef and kitchen assistants, domestic staff and a maintenance person. The home employs an Activities Organiser. Clare House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out as part of the regulatory process. A total of 15 hours were spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff files and maintenance records. 9 service users, 5 visitors and 7 staff were spoken to as part of the inspection process. Of the CSCI comment cards sent to the home prior to the inspection, 12 service users cards were returned. No relatives/visitors cards were returned, but it was noted that relatives had completed some of the cards on behalf of the service users. Feedback from the comment cards was given to the Manager Designate in a general manner. The pre-inspection documentation completed by the home was also examined to inform the inspection. The Manager Designate had been in post for one week and was open and receptive during the inspection. It was clear from discussion that she was in the process of auditing the home to identify any areas in need of attention. What the service does well: What has improved since the last inspection? What they could do better: Clare House Version 1.10 Page 6 The Manager Designate had already identified the need for more frequent fire drills, and this, together with ensuring an up to date Fire Risk Assessment is available in the home, will improve fire safety in the home. Areas of the home were in need of redecoration, and this must be addressed and finance made available to carry out the necessary work to bring the home up to an overall good standard of décor and furnishings. The home is reviewing emergency protocols to include emergency ambulance calls to ensure all staff are fully aware of the procedures to be followed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clare House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Clare House Version 1.10 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 standard(s) 1, 2, 3, 4 & 5. The home does not provide intermediate care. Service users are provided with information about the home and all service users have a written contract/agreement, so as to be clear about the services the home provides to meet their needs. The information is in the process of being reviewed to provide up to date information. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training to meet service users needs, including specialist needs. Prospective service users and/or their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: Service users, their relatives and representatives are provided with information regarding the home in the form of a Service Users Guide and Statement of Purpose. These documents are in the process of being reviewed to contain up to date information. Some service users spoken with were unsure where their copy of the Service Users Guide was, and the Manager Designate said she would ensure that with the new Service Users Guide, all service users were made aware of the documentation. Clare House Version 1.10 Page 9 The Bursar was not available on the second day of inspection, so financial and contractual records will be viewed at the next inspection. The BUPA terms and conditions and contract for placements is in the process of being updated and the Manager Designate said that up to date copies will be included in the new Service Users Guides. The pre-admission assessment document is comprehensive, and some completed documents were viewed. These provide a clear picture of the service users needs. An NHS registered nurse carries out the assessments for NHS funded nursing care. Staff had received training in topics relevant to the care of the elderly and palliative care. The Deputy Manager ensures that staff are kept up to date in the needs of service users, to include any changes, which can occur swiftly, especially for service users with palliative care needs. The home receives input from local churches, and would arrange for input for any specific religious care needs. The Registered Manager said that whenever possible, prospective service users are encouraged to visit the home, and meet other service users and staff. However, it is usual for a representative of the service user to visit on their behalf. Service users spoken to said that their representatives had visited the home on their behalf and visitors spoken with said that they had visited the home and had the opportunity to discuss any points they wished to. The home does not accept emergency admissions at the present time. Clare House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 The health and personal care needs of service users had been identified and were being met. Improvements were noted in the completion and content of the service user plans, with some shortfalls requiring addressing to ensure that the service users current needs are fully identified and met. Generally medications were being well managed, so as to ensure service users medication needs are met. Service users were being treated with respect and courtesy, and the changing needs of service users were being identified and met. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users’ identified health, personal and social care needs would be met. There was evidence of new care plans being formulated to address newly identified needs. Service users plans were up to date and had been reviewed monthly and whenever there was a change in the service users needs. There was evidence of representative involvement in the formulation of service user plans, and some visitors spoken with said that they had been involved in the plan of care. Where this had not been done, this was promptly addressed. Daily record entries were very general and needed expanding to give a clear picture of the care given to each service user. The documentation viewed for wound care to Clare House Version 1.10 Page 11 include pressure sore risk assessments was comprehensive, identifying each wound with the plan of treatment to be followed. The Deputy Manager is very ‘hands on’ and is directly involved with the wound care and monitors the progress of each wound closely. Pressure relieving equipment to meet the assessed needs of the service users was seen in use in the home. Assessments for moving and handling, nutritional screening and continence management were in place. In one instance the moving and handling assessment had not been updated to reflect changes in the service users condition. Care plans for continence care needed reviewing to include all continence care needs. Risk assessments for identified areas of risk had been completed. In one instance the risk assessment for falls did not indicate a history of falls, which were documented on a separate form. A review of the service user plans to ensure that the documentation contained therein is current and all other documentation, to include obsolete documents, is archived, was discussed. Risk assessments and signed consents for the use of bedrails had been completed, and one service user said that they had requested bedrails and a full explanation and assessment, plus signed consent, had been undertaken to ensure they fully understood any risks. Concern regarding the frequency of GP visits had been expressed on some comment cards, and this information was discussed with the Manager Designate. The home has input from other healthcare professionals, to include Macmillan nurse specialists. Samples of the medication administration records were viewed. The drugs fridge temperatures were within acceptable range. The room temperature is recorded each morning and the need to record it to reflect the highest temperature reached during the day was discussed. One service user is selfmedicating and an assessment had been completed in 2003 and a review of this was discussed. The service user described the security measures employed for the storage of medications and ensures medications are locked away whenever they are unattended. Liquid medications had the date of opening written on. The medications are well managed in the home. Staff were seen to address service users in a courteous manner. Service users and visitors spoken with were satisfied with the standard of care provided and the attitude of the staff, and some were very complimentary about the care they receive. Staff spoken with said that they undergo induction training during, and this includes treating service users as individuals and identifying their personal needs. The home is registered for 3 palliative care beds. The Deputy Manager is very experienced in this area of nursing, and training has been provided for the staff. The service user plans are updated whenever there is a change in the service users condition, and the home aims to ensure that the wishes of service users and their representatives concerning their care in their final days are recorded and respected. The home has good support from the Macmillan nursing team and the dispensing pharmacist. Polices and procedures for death and dying are in place. Clare House Version 1.10 Page 12 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 standard(s) 12, 13, 14 & 15 Social activities are in place in accordance with service users wishes. Visiting is encouraged for service users to maintain contact with family and friends. Service users choices in their care and routines are respected within the homes capabilities. Dietary needs of service users are well catered for with food choices provided and food available that meets service users preferences. EVIDENCE: The home has a full time activities organiser who is enthusiastic and knowledgeable about her role. The activities programme was on display in the home, as were photographs of outings and examples of craft activities undertaken. The Service users spoken with said that they enjoyed the activities and outings arranged, and others said that they could choose which activities they wished to participate in and that their wishes are respected. Relatives and friends were seen visiting service users. The home has formulated an information document on the homes policy for maintaining contact between service users and their relatives and friends, which is informative. Service users can choose whom they wish to see and their wishes are respected. The activities organiser arranges involvement from local community groups and outside entertainments. Choices are offered in each aspect of the care provision and routine of the home. Service users spoken with said that they can choose where to spend Clare House Version 1.10 Page 13 their time and what activities they participate in. The Manager Designate said that the lunch mealtime was to be reviewed to ensure it meets the needs of the service users. Bedrooms viewed were personalised and service users can have access to their personal records as they so wish. The lunches on both inspection days were sampled and were well presented and tasty. Service users spoken with said in general the meal provision was satisfactory and that they are offered choices. Menus were available and reflected choices. Clear lists of service user choices are kept and service users are asked the previous day for their meal choices. There are set mealtimes, but if a service user is absent or does not wish to eat at that time, alternative arrangements can be made. Nutritional screening, dietary likes and dislikes and special diet needs are recorded in the service user plans and this information is given to the chef. Some concern regarding the meal provision was expressed on the some of the comment cards received, and it is recommended that the meal provision be reviewed on an ongoing basis, with input from service users. Clare House Version 1.10 Page 14 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 standard(s) 16, 17 & 18 The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. Systems are in place for the protection of vulnerable adults, so as to protect them from possible risk of harm or abuse. Advocacy services are active in the home and service users legal rights are protected. EVIDENCE: The home has a detailed complaints procedure, which is available and displayed in the home. Complaints records viewed clearly recorded the action taken by the home to investigate the complaint, address any shortfalls, the outcomes and copies of all correspondence. Nine complaints had been received by the home since April 2004 and had been addressed. Where complaints have been copied to the CSCI, copies of correspondence have been forwarded by the home. Service users and visitors spoken with said that generally concerns raised are addressed, and that the Deputy Manager is very prompt in dealing with any issues, and this was also evidenced at the time of inspection. Two specific complaints regarding emergency procedures had been received, and where shortfalls have been identified, an action plan to address these findings has been formulated and the Manager Designate said that she would ensure that this is fully addressed. Notifications of the next visit by the homes’ Advocate were on display in the home. Postal votes are arranged for any service users able and wishing to vote. Clare House Version 1.10 Page 15 The home has a clear procedure for the protection of vulnerable adults (POVA), and generally this dovetails with the Local Authority documentation. However, one aspect identified at the last inspection as not clearly dovetailing the procedures to be followed had not been amended. The Manager Designate said that BUPA were aware of this finding and are reviewing the documentation for clarity. Staff had received training in POVA and those asked said that they would report any POVA concerns to the Management and were aware that they could also contact Social Services. Procedures for the management of service user aggression to include challenging behaviour are in place. Policies and procedures for service user finances are in place, and are in the process of being updated by BUPA. It was clear that the Manager Designate understood the POVA procedures to be followed in the event of an allegation being made. Clare House Version 1.10 Page 16 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 standard(s) 19, 22, 25 & 26 The home is generally clean and tidy and the environment is safe for service users.This provides service users with a comfortable and safe environment for those living there and visiting. A review of the premises with regard to decoration and refurbishment is required to ensure that the premises are maintained to a good standard. The home was inspected by the London Fire & Emergency Planning Authority in May 2004, at which time the home was found to be satisfactory. Equipment and adaptations to meet service users needs are in place. Policies and procedures and staff training for infection control are in place to safeguard service users from infection. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. The corridors and some of the rooms needed decorative attention and the Manager Designate was aware of this and agreed to carry out a full audit of the home in respect of décor, fixtures, furnishings and floorings so that a programme of maintenance and redecoration and refurbishment of the premises can be drawn up. The bedroom doors have self-closure devices, which activate when the fire alarm sounds. The London Fire & Emergency Planning Authority last carried out a fire inspection of the premises in May 2004 and found them to be Clare House Version 1.10 Page 17 satisfactory. The entrance and gardens are maintained with splashes of colour providing a cheery welcome and outlook. The home has a passenger lift and there are rails in the corridors and in the toilet facilities. The corridors allow wheelchair access. In some instances it is not possible for service users who self-propel to exit the bedroom doors easily without assistance, and this is provided by staff. Service users are assessed to ensure that the correct moving & handling equipment is identified for their use. There appeared to be adequate storage facilities. The home has a call bell system and service users spoken with said that generally the response to the call bell was prompt, showing an improvement since the last inspection. Staff spoken with were clear that bells must be answered promptly and understood how the system functioned. Problems with the emergency lighting had been addressed promptly following the last inspection and the records evidenced regular checks are being carried out. Generally the lighting was satisfactory, and the Manager Designate said that should there be any concerns from service users regarding the lighting, then this would be addressed. Monthly water temperature checks are carried out and where temperatures are found to be outside the designated safe range, corrective action is taken. The home was clean and odour free throughout. The laundry assistant was clear regarding the laundry procedures to be followed when dealing with infected laundry, and also on the secure storage of substances that could be hazardous to health. The home has policies and procedures in place for infection control and the staff training records evidenced ongoing training in this area. Clare House Version 1.10 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 Overall the systems for the recruitment of staff were robust so as to safeguard service users. The provision of in house training is good and ensures that the identified training needs of individual staff are addressed and that staff have the necessary skills to meet service users needs. The home is aware of the need for ongoing NVQ training for care staff. EVIDENCE: The home is staffed to meet the minimum staffing notice agreed with the previous registering authority. The management are aware of the need to keep staffing levels under review on an ongoing basis to ensure that the changing needs of service users are met. Thie need keep staffing levels and skill mixes under ongoing review to ensure that the needs of service users can be met at all times was discussed, and the management were very clear on this. The home was clean, tidy and odour free and ancillary staff are employed in appropriate numbers to maintain a good standard of cleanliness. There are 4 staff qualified to at least NVQ level 2 and 7 staff currently undertaking the award. Student nurses are employed on the bank staff. The Deputy Manager said that the induction and foundation training for staff is to recognised standards. The staff employment files viewed contained details of the applicants completed application forms, medical declaration, 2 references, copies of passports, plus terms & conditions of contract and job descriptions. Criminal Record Bureau checks had been carried out. Two files did not contain a recent photograph and the Registered Manager said that this was in the process of Clare House Version 1.10 Page 19 being addressed. There was evidence of Nursing and Midwifery Council verification having been carried out for the registered nurses. The need to ensure that staff are not working excessive hours was discussed, and it is recommended that all staff declare any additional employment. Clare House Version 1.10 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 & 38 The home is well managed and the Manager Designate and Deputy Manager have an open style of management. Meeting the service users needs is a priority with all staff and there is good support from the management team. Staff work together to meet the needs of the service users. Clear systems for quality assurance are in place so as to enhance the quality of life for service users. EVIDENCE: The Manager Designate had been in post for one week and she had an open and positive approach to the inspection. The Manager Designate is a first level registered nurse and is due to commence the registered managers award in May 2005. She has completed periodic training relevant to the service user group. The Deputy Manager is also supernumerary and is clear in her role of ongoing training and supervision of staff, plus is very involved with the care and review of service users. Visitors and service users spoken with were generally complimentary about the attitude and approach of the management Clare House Version 1.10 Page 21 and staff. There are clear lines of accountability within the management structure of the company. The home has an Equal Opportunities policy and this is practiced. Copies of the General Social Care Council codes of practice are given to care staff, so that they have an understanding of the overall expectations of them in all areas of their work. The registered nurses abide by the Nursing and Midwifery Council Code of Professional Conduct and associated publications. The notification of inspection poster was displayed in the home. The home has an annual audit for quality assurance, which covers all aspects of home management and facilities. The Manager Designate had begun to assess and prioritise areas needing review. An annual survey of service users and their representatives is also carried out and the results collated centrally by BUPA and the report sent to each home. BUPA has a Personal Best Customer Care training programme and some staff spoken with said that this provided good training in the care of service users as individuals. Policies and procedures were up to date and the system of review is clearly recorded at the front of each folder. Service user and relatives meetings are held and service users and their relatives are encouraged to voice any issues they wish. The Bursar was not present on the second day of inspection, and the financial aspects of the home will be examined at the next inspection. Some progress had been made with formal supervision for staff. A matrix to easily evidence that staff receive formal supervision 6 times a year is to be formulated. This will be reviewed at the next inspection. All staff are supervised on a day to day basis as part of the management of the home. Servicing records were viewed at random and those viewed were up to date. The fire manual maintenance records were up to date and staff had received fire safety training. The Manager Designate had already identified the need for more frequent fire drills to ensure that staff are familiar and confident with the processes to be followed. The fire risk assessment for the whole premises was not seen at the time of inspection and the need to ensure that this is carried out annually and whenever there are any relevant changes was discussed. Evidence that the home meets the Water Supply (Water Fittings) Regulations 1999 was not seen. This had been discussed with the previous Home Manager. The Manager Designate said that she would find out if the home complies and take any necessary action. There are comprehensive Health & Safety policies and procedures in place. Clare House Version 1.10 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 x x 3 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 2 x 2 Clare House Version 1.10 Page 23 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 6 Requirement The Statement of Purpose must be updated. This must be freely available in the home and copy must be submitted to the CSCI. The Service Users Guide must updated. Copies must be provided to each service user and a copy submitted to the CSCI. The daily records must give a clear picture of the service users current condition. Moving and handling assessments must reflect the service users current condition and moving and handling needs. Care plans for continence care must reflect all continence care needs for each service user. A full audit of the home must be carried out to identify the redecoration and refurbishment needs of home. An action plan must be drawn up to address the findings, prioritising the areas in most need of attention, with timescales for completion. Staff records must contain all the information required under Schedule 2 of the Care Homes Regulations 2001 Version 1.10 Timescale for action 01/06/05 2. 1 6 01/08/05 3. 4. 7 8 17 13 01/06/05 13/05/05 5. 6. 8 19 17 23 13/05/05 01/06/05 7. 29 17 Schedule 2 01/06/05 Clare House Page 24 8. 9. 36 38 18 23(4) 10. 38 13 A system to identify that staff supervision has been carried out 6 times a year must be in place. Evidence of the Fire Risk Assessment for the premises, formulated in line with the London Fire & Emergency Planning Authority guidelines must be available in the home. This must be updated annually and whenever there is a relevant change to the home. There must be evidence that the home fully complies with the Water Supply (Water Fittings) Regulations 1999. 01/06/05 01/05/05 01/06/05 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. Refer to Standard 8 8 9 Good Practice Recommendations It is recommended that the service users plans be reviewed and any out of date documentation removed and archived. It is recommended that the GP cover for the home, to include holiday cover, be clarified to ensure ongoing regular input to the home. It is recommended that the time of day for recording the fridge and room temperatures in the medications room be reviewed to ensure that the maximum temperatures for medication storage are not exceeded. It is recommended that the meal provision be reviewed on an ongoing basis, with input from service users. It is recommended that all staff are asked to declare any additional employment so that the home can be clear that staff are not working excessive hours which could effect their ability to carry out their duties satisfactorily. 4. 5. 15 30 Clare House Version 1.10 Page 25 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Clare House Version 1.10 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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