Inspection on 13/12/06 for Clare House

This inspection was carried out on 13th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Clare House 07/11/08

Clare House 29/10/07

Clare House 19/04/06

Clare House 27/09/05

Clare House 19/04/05

Clare House 30/11/04

Clare House 02/06/04

Clare House 01/03/04

Clare House 16/04/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Clare House Whittlebury Road Silverstone Northants NN12 8UD Lead Inspector Irene Miller Key Unannounced Inspection 13th December 2006 11:30 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 Clare House DS0000012744.V323954.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. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clare House Address Whittlebury Road Silverstone Northants NN12 8UD 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) 01327 857202 01327 858976 apopat@btconnect.com Clarex Limited Vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 named person may be accommodated over the age of 62 years No one in the category of DE (E) may be admitted to the home if there are already 5 service users in this category accommodated within the home. To limit the number of service users in the categories DE (E) 19th April 2006 Date of last inspection Brief Description of the Service: Clare House is a detached property situated in the village of Silverstone to the south of Northampton and is set back from the road in pleasant gardens. The home is registered to provide personal care for up to 25 residents over the age of 65 years, including up to five people with a diagnosis of dementia. There is an ongoing process of refurbishment to update and improve the facilities. There is a communal lounge, two conservatories, library area and a large pleasant dining room that can accommodate all of the residents at meal times. Bedrooms are over three floors with a passenger lift for access to the first floor. All bedrooms are single rooms. Fees range from £350.00 for a standard bedroom to £465.00 for a large bedroom with en-suite facilities. There is a main kitchen catering for all the main meals and a refurbished laundry to cater for all the residents needs. The registered provider is Mr Atul Popat; the position of registered manager is vacant. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for Service Users and their views of the service provided. This inspection was a second ‘Key Inspection’ that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. Prior to the inspection taking place the Commission for Social Care Inspection sent out to the home a pre-inspection questionnaire for completion by the Registered Manager. The completed pre-inspection questionnaire was returned to the Commission for Social Care Inspection and provided information on the management systems within the home. The primary method of inspection used was ‘case tracking’ that involved selecting three residents and reviewing the care that they received and viewing written information on their care, such as the care plans (a care plan sets out how the home aims to meet the individual residents personal, healthcare, social and spiritual needs). Discussion took place with residents, staff and visitors, the registered provider and staff and general observations of care practices were made. Policies, procedures and records in relation to staff recruitment, complaints, and general maintenance and upkeep of the home were viewed. The registered provider Mr Atul Popat was available at the home throughout the inspection. The inspector spent two hours planning the areas to focus on at this inspection, based upon information gained from reviewing the homes service history, the last two inspection reports and information from the pre inspection data collection system. The inspection took place over a period of approximately six hours. What the service does well: Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 6 In the absence of a registered manager to provide leadership and to oversee the day-to-day management of the home, the staff team continue to meet resident’s needs, ensuring that they are cared for with respect and dignity. Comments from visitors were very positive, that the staff makes them welcome and that the staff are approachable, the registered provider was observed to relate well with residents, staff and visitors to the home. What has improved since the last inspection? What they could do better: The refurbishment work has taken place over approximately ten months and is almost to completion, the concerns raised with the Commission for Social Care Inspection provided the means for the fire safety protection and building controls officers to meet with the registered provider to ensure that the works fully complied with fire and building regulations, it would have been prudent for the registered provider to have consulted with the authorities prior to starting the building works. Falls risk assessments need to be implemented, balancing the resident’s rights to make choices and how the home aims to protect their health, safety and welfare. The risk assessments in place addressing environmental hazards around the home and workplace need to be reviewed and updated were necessary. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 7 Risk assessments need to be fully accessible to staff and other interested parties to ensure that all are aware of potential hazards and the control measures in place. The employment of an activity co-ordinator should provide a resource to ensure that activities take place on a regular basis, and enable resident’s to maintain contact with the community meeting individual and group preferences. The registered provider needs to formalise how they respond to concerns or complaints raised, there was no records available of review meetings that had been held with residents and their representatives. The appointment of a registered manager to oversee the day to day running of the home would provide leadership and support for the staff team and release the registered provider to discharge his business responsibilities fully. 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. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (standard 6 is not applicable to this service) Quality in this outcome area is good. The admission procedure ensures that prospective service users only move into the home once it has been established that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was pre admission assessments viewed outlined the prospective residents personal care, health and social needs, and had been signed and dated by the registered provider that conducted the assessment. Residents are given the opportunity to visit and assess the quality of care prior to moving into the home. Clare House DS0000012744.V323954.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): Standards 7,8 & 10 Quality in this outcome area is good. In general the resident’s health and personal care needs are met, however shortfalls in risk assessment processes could place the residents personal safety at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed the residents health and personal care needs had been identified, and there was moving and handling, nutrition and dependency level assessments in place. Where residents had been assessed at risk of developing pressure ulcers, due to poor mobility and failing health, there was additional support provided from the district nurse. One resident case tracked had encountered several falls and the staff had completed accident reports, however there was some concern that a risk assessment had not been implemented to identify what may have contributed the falls incidents; where risk assessments had been implemented they lacked regular reviews taking place. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 11 Medication was not inspected on this visit, the key inspection of 19th April 2006 identified that the medication storage and administration records were in order, a medication policy was in place and only designated staff that have received full medication training administer medication to residents. There were records of visits by the residents General Practitioner in response to the changing healthcare conditions of residents and to review residents prescribed medications. During a tour of the building it was noted that one ground floor bedroom directly overlooked the entrance gate and garden patio area, although having a pleasant outlook privacy screening was only available to one window, and this could infringe on the residents rights to privacy. Staff and resident interactions observed during the inspection indicated that the staff cared for residents with sensitivity and respect. Residents said that the staff were very friendly and helpful. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is good. In general the home matches the residents social, cultural, religious and recreational expectations, however there is a reliance on relatives to provide the means for residents to maintain contact with the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the care plans viewed there was information available on the individuals personal, social and cultural hobbies and interests, this formed the basis for staff into providing person centred activities for residents. Within the care plans viewed there was records of residents participating in their chosen activities, such as going out for lunch with family, reading books, watching TV, and listening to music. One of the residents case tracked chose not to participate in social activities, preferring to spend time within their bedroom reading and watching TV, and there was evidence within the bedroom that demonstrated that the home had accommodated this particular resident’s wishes such as books, magazines and Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 13 newspapers, the resident was watching TV and when asked how they liked to spend their time, they confirmed that they liked being in their own room. Within the front entrance area there was a notice board available and a list of weekly activities was on display, activities such as board games, bingo and crosswords, and of church visits from the clergy. On the day of inspection the afternoon activity was listed as board games, however this activity was not observed to take place. During the afternoon residents were observed within the lounge, some watching TV and two residents were observed to be sleeping, care staff were observed to come into the lounge and chat with residents The inspector visited three residents within their bedrooms, two were occupied watching the snooker on TV and one resident was spending time with their relative who was visiting. When asked about the provision of activities within the home, residents said that they were generally satisfied with what was available, saying that the ‘girls sometimes spends time with them’ and ‘that they do all that they can’, one resident said that they enjoyed going out for pub lunches with their daughter. Residents spoken with said they liked living at the home that the staff were very nice and helpful and that they felt that they were treated with respect, one resident said that the staff were very nice although the other ‘tenants’ didn’t seem to speak much to each other. The home does not employ an activity person/co-coordinator, however the registered provider had created a position of resident and visitor liaison person, the aim of the position was that a member of staff would focus on spending time with residents and visitors on a social level. In discussion with the registered manager it was established that the position had not been available for a several months, however it was expected that the position would be resumed within the next few weeks. Comments from visitors were positive, when asked what the home does well visitors said that the staff were friendly and welcoming, helpful caring and kind. When asked what could the home do better, it was suggested that more could be done within the home to promote activities for residents. Since the last key inspection visit of 19th April 2006 no organised outings had been provided by the home, the registered person said that this area has been discussed with families, who had said that they would rather take their relative on outings on a one to one basis. The registered manager confirmed that in house activities planned to take place in the run up to Christmas included a visit from children from a local Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 14 primary school to sing Christmas carols, a musical entertainer to play the keyboard and a New Year party due to take place on 12th January 2007. The dining room was clean, pleasant and welcoming, residents said that they were pleased with the food available, the meal on the day of inspection was lamb with mint sauce, mashed potatoes and mixed vegetables. There were records available to demonstrate that the home seeks to accommodate resident’s food preferences and there were records available of resident’s that had food allergies. Following a recent inspection by the Environmental Health the home has introduced new food safety monitoring systems, following the Safer Food Better Business food safety guidance. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is adequate. To ensure that residents and their representatives can be fully confident that their complaints will be listened to, taken seriously and acted upon, the registered provider needs to formalise how they respond to concerns or complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was information available within the front entrance area on how to raise any concerns or complaints about the service. Since the last inspection the Commission for Social Care Inspection (CSCI) had investigated one formal complaint about the home, following a complainant’s dissatisfaction with the registered providers response to concerns they had raised. Concerns had been brought to the attention of CSCI in relation to the safety and protection of resident’s due to the extensive building works being under taken at the home. CSCI sought the involvement of South Northamptonshire District Council Fire Protection Department who acted upon the information and conducted an unannounced Fire Safety Inspection of the premises. The registered provider has complied in meeting the fire precaution requirements issued by the Fire Authority who continue to monitor the progress of the works. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 16 The registered provider has endeavoured to improve communication with residents relatives and held meetings with residents and their relatives to discuss any issues of concern and review the residents on-going care needs, however no formal records of the meetings were available to view. Staff training was available on the protection of vulnerable adults and the home had a copy of the Northamptonshire Protection of Vulnerable Adults Inter Agency Policies and Procedures to follow should there be any incidents or allegations of suspected or actual abuse occur. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,24,25 & 26 Quality in this outcome area is adequate. In general residents live in a home that has a pleasant internal and external environment, however the failure of the registered provider to fully consider the suitability of the environment and relevant legislation potentially placed residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit extensive building and refurbishment work had been carried out, however the Commission for Social Care Inspection (CSCI) were alerted to concerns raised in relation to fire safety and the health, safety and welfare of residents, staff and visitors whilst the works were in progress. The Commission for Social Care Inspection sought the involvement of the South Northamptonshire Fire Safety Authority who conducted an unannounced inspection of the premises, together with the a buildings controls officer, Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 18 following the visit requirements were issued to the registered provider to comply with the Building Regulations and Fire Precautions (workplace) Regulations 1997 (as amended) The registered provider has fully complied with requirements issued by the Fire Safety Authority, who continue to monitor the progress. The building and refurbishment work has enhanced the internal and external communal space available for residents. A second conservatory had been added to the front of the property, however no fixed heating had been incorporated when building the conservatory and it was observed that no residents were using this new facility. Within the existing conservatory leading from the residents lounge, a portable wall heater had been recently installed which had an additional cooling facility for summer use, the registered provider explained that this heater was being tested to assess its suitability, and should it provide sufficient heat output a second unit would be purchased for the new conservatory. Risk assessments had been implemented addressing the control measures for minimising falls and tripping hazards due to outside building works and storage areas, and control measures in place whilst the main staircase was out of use. However the risk assessments viewed required reviewing and updating, one risk assessment referring to a temporary fire exit in use was dated 27th February 2004 and there was no indication that any review had taken place since its initial implementation. Therefore the requirement made following the key inspection of 19th April 2006 that risk assessments are in place to address significant hazards relating to the health, safety and security of residents, staff and visitors throughout the homes refurbishment stages was partially met. The Commission for Social Care Inspection carried out a random inspection on 4th July 2006 and it was noted that staff did not have access to these risk assessments. The registered provider was reminded that risk assessments are working documents and that all persons likely to come into contact with the identified hazards must be aware of the control measures put in place to ensure their health, safety and welfare as far as reasonably practicable. The fire alarm call points are activated on a set day each week, however the records of the tests indicated that the fire alarm equipment had not been tested the week previous to the inspection taking place, a designated member of staff holds the responsibility for conducting the tests, and in their absence there was no management system in place to ensure that the tests continue to take place. A fire safety risk assessment had been carried out, and all staff had received fire training. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 19 A tour of the building was conducted and resident’s rooms viewed were furnished to a high standard and in the main pleasantly decorated and personalised with pictures, ornaments, television, radio and small items of individual furniture. Furnishings throughout the home were pleasant and of a good standard and suitable to the needs of the residents living at the home. The communal lounge required redecoration mainly due to due to rewiring that had taken place, and the lighting was not fully operational; the lounge had four double wall lights that each had one non functioning bulb and no central light was available. There was some internal and external works yet to be completed, these included the fitting of fire resisting door seals, during the tour of the building it was noted that bedroom doors had been fitted with self closing devices, however some required attention as they did not fully close. The bathrooms and toilets were decorated to a good standard, and personal protective equipment was available for staffs use. The mattresses and bedding had been removed from the walk in bath facility on the ground floor (on the key inspection of 19th April this bathing facility was being used as a storage area), the removal of the materials ensured that the bathroom was fully accessible should a resident wish to use it. The laundry had been refurbished and the registered provider had complied with the requirements under the fire precautions (workplace) regulations 1997 (as amended), following the fire inspection visit. The second conservatory operates as the main entrance and exit of the home, it was noted that the raised threshold to this door was approximately 10 cm in height and for residents and visitors with limited mobility posed a potential tripping hazard. This was discussed with the registered provider who confirmed that a bespoke ramp was in the process of being manufactured, and that plans were being made to have an assessment carried out on the home to ensure that the internal and external environment complied with the Disability Discrimination Act 1995. A large patio had been laid outside the second conservatory and outdoor seating had been purchased creating a pleasant outdoors area, and outside security lighting had been installed. The entrance to the home is kept locked, all staff had a key on their person and in the event of a fire or emergency there was a key available within the break point next to the door. Due to the door being locked visitors are required to ring the door bell and wait for a member of staff to open the door, the registered provider confirmed that plans were in hand to fit a storm/shelter Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 20 canopy above the new entrance door, so that visitors have some shelter in inclement weather. Clare House DS0000012744.V323954.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): Standard 30 (standards 27,28 & 29 were inspected during the key inspection of 19th April 2006) Quality in this outcome area is good. The staff are appropriately trained to carry out their duties to the full. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff training records viewed demonstrated that all staff had received recent fire training, the method of training was through the use of a DVD fire training package that included a multi choice questionnaire to embed knowledge. The home employs staff from overseas and from within the European community, staff recruitment records were viewed and demonstrated that there was thorough recruitment procedures in place. Training is also available from the Learning and Skills Council on reading and writing for staff that have English as their second language. Staff spoken with said that they enjoyed working at the home; one member of staff had previously worked at the home and had returned, saying that they had missed working at the home and that caring for the elderly was very rewarding. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 22 Clare House DS0000012744.V323954.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): Standards 31,33 & 38 (standard 35 was inspected during the key inspection visit of 19th April 2006) Quality in this outcome area is adequate. The continual absence of a registered manager hinders progress in developing the management and administration of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered provider has endeavoured to manage the day to day running of the home, however where the owner is not the registered manager a registered manager must be in place, The registered provider has sought the assistance of two management recruitment agencies in seeking a suitable candidate for the manager’s position, and has submitted to the Commission for Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 24 Social Care Inspection some evidence to demonstrate their commitment to finding a suitable manager for the home. From the care plans viewed, one resident had encountered several falls, and there was some concern that a risk assessment had not been implemented to identify any physical, psychological or environmental cause for the falls incidents, and where risk assessments had been implemented they lacked regular reviews taking place. The registered provider said that they would in future be monitoring the progress of the care planning and risk assessment processes, this is an area, which a registered manager would oversee, monitor and manage. The generic risk assessments in relation to the internal and external environment and working practices required updating and reviewing. The registered provider has endeavoured to improve the standard of the homes internal and external environment, and the outcome is that the residents are provided with a pleasant home with good facilities. The registered provider has demonstrated their compliance in meeting the requirements issued from the fire protection and building controls inspection. All staff had received fire training, and a fire risk assessment had been carried out. Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 25 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 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 X X 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X X X X 2 Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 26 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 2 Standard OP8 OP16 Regulation 13 (4) (b) 22 (3) Requirement Falls risk assessment must be in place for residents that are identified at risk of falls. The registered provider must keep open and transparent records of any concerns or complaints made and details of their investigation and actions taken. The registered provider must have in place a programme of routine maintenance to all selfclosing door devises to ensure that they are fully operational. The registered provider must update the Commission for Social Care Inspection each month in writing, the steps they have taken in recruiting a registered manager for the home. In addition the registered provider must produce to the Commission for Social Care Inspection copies of job advertisements, application forms and interview records to demonstrate that a registered DS0000012744.V323954.R01.S.doc Version 5.2 Page 27 Timescale for action 31/12/06 31/12/06 3 OP19 23 (4) (5) 31/12/06 4 OP31 8 (1) (a) (b) (ii) 31/12/06 8 (2) Clare House 5 OP31 10 (3) 6 OP38 13 (4) (c) (6) manager is actively being sought. Where the registered provider is in day-to-day control of the home, he must meet all of the standards applying to the registered manager. Risk assessments covering the internal and external environment and safe-working practices must be reviewed at regular intervals and updated as necessary. 30/06/07 31/12/06 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 OP10 Good Practice Recommendations The registered provider should ensure that bedrooms that are overlooked from the garden preserve the occupants rights to privacy. The registered provider should consider appointing an activity organiser to enable residents to maintain contact with the community as they wish, and to further promote in-house activities. The registered provider should ensure that an assessment is carried out on the home, to ensure that the internal and external environment complies with the Disability Discrimination Act 1995. 2 OP13 3 OP19 Clare House DS0000012744.V323954.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Clare House DS0000012744.V323954.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. Re-publishing this information is in breach of the terms of use of that website. 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