Inspection on 30/08/06 for Clare House

This inspection was carried out on 30th August 2006.

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 24/10/05

Clare House 11/04/05

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 Mrs Clare Henderson Roe Key Unannounced Inspection 30th August 2006 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 Clare House DS0000010928.V306491.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 DS0000010928.V306491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clare House Address Harefield Road Uxbridge Middlesex UB8 1PJ 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) 01895 272 766 01895 272 896 www.bupa.com BUPA Care Homes (BNH) Limited Mrs Anna Francis Dempsey Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To comply with the Minimum Staffing Notice required by the previous regulator as at 31st March 2002. One named service user with Dementia can be accommodated, as agreed by the NCSC on 21/1/04, for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. Three of the beds currently registered may be used as Palliative Care beds. 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. 24th October 2005 3. 4. Date of last inspection Brief Description of the Service: Clare House is a 43-bedded Care Home providing nursing care for 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 washbasin. There are four double rooms, all with en suite facilities, which are used for single occupancy. 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 newly appointed, a receptionist, an administrator, registered nurses, care staff, chef and kitchen assistants, domestic staff and a maintenance person. The home employs an Activities Organiser. The fees range from £750 to £950 per week, dependent on the service users assessed needs. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 10 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 7 service users, 5 visitors and 9 staff were spoken with as part of the inspection process. The pre-inspection questionnaire, sent to the home at the time of inspection, has also been used to inform this report. What the service does well: The home is being effectively managed and staff and service users commented that the Registered Manager is supportive and approachable. Prospective service users are fully assessed prior to admission to ensure the home is able to meet their needs, and confirmation of this is provided in writing. Service user plans are comprehensive and up to date, giving a clear picture of the service users and how their needs are to be met. Staff care for service users in a courteous and gentle manner, and service users spoken with said that they are well cared for and enjoy living at the home. The activities provision in the home is commendable, with much thought and care taken to provide a variety of activities to meet each service users interests and abilities. The home has an open visiting policy and visiting is encouraged. Age Concern Advocacy Service information is freely available in the home, so that service users can obtain independent representation if they so wish. The food provision in the home is good, with choices being offered. Service users spoken with said that they enjoy the food. Robust systems are in place for the management of complaints and adult protection issues. There is evidence of ongoing redecoration and refurbishment and the Registered Manager ensures that areas requiring attention are addressed in a timely manner. The bedrooms are personalised and homely, and overall the home is clean, fresh and has a good atmosphere. Equipment for the prevention of pressure sores and for moving & handling of service users is available to meet the service users assessed needs. The home is appropriately staffed to meet the service users needs. Staff have received training to provide them with the skills and knowledge to provide a good standard of care to service users, to include health & safety training and updates. Systems in place for staff recruitment are robust, thus protecting service users. Processes for quality assurance are in place, and the home strives to improve year on year. There are comprehensive systems in place for the management of service users personal monies, and these are well managed by the homes administrator. Individual staff supervision sessions are carried out on a regular basis, and staff are well supported by management. Risk assessments for equipment and safe working practices were in place, with Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 6 the exception of the kitchen area. Up to date health and safety procedures are available in the home. 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. Clare House DS0000010928.V306491.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 Clare House DS0000010928.V306491.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: The Registered Manager carries out a pre-admission assessment on all prospective service users in order to ascertain that the home can meet the service users needs. Where available a copy of the Social Services needs led assessment is also obtained. Following assessment the Registered Manager agrees in writing if the home is able to accept the service user. A contract is agreed and signed prior to admission. Clare House DS0000010928.V306491.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Medications are generally being well managed at the home, but shortfalls could potentially pose a risk to service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: The Inspector viewed 3 service user plans. These were comprehensive and up to date, providing a clear picture of the service users needs and how these are to be met. The documentation had been updated monthly and whenever there was a change in the service users care. New care plans had been formulated for any new needs identified. There was evidence of input from the service user and/or their representative. Another service user plan was viewed specifically in respect of recording following a fall. The documentation was in place and up to date and staff were clear of the areas to be updated following any falls. Risk assessments for all identified risks had been completed in each service users file viewed. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 10 There were no service users with pressure sores at the time of inspection. Risk assessments for pressure sores were in place and pressure relieving equipment was seen in use. One service user had a wound and the documentation for this was up to date and clearly recorded the treatment and progress of the wound. Assessments for nutrition, moving & handling and continence had been completed, and where problems had been identified, care plans had been formulated. The moving & handling equipment to be used for each service user had been identified in the service user plan. Risk assessments for the use of bedrails and written consents were in place. The service users are registered with a GP who visits the home each week and at other times if necessary. Records of input from other healthcare professionals were available and up to date. The home uses the NOMAD 7 day system for receipt of medication from the dispensing pharmacist. Medication records were sampled. There is a front sheet for each service user containing information to include their photograph and date of birth, GP, any known allergies, date of admission and room number. Allergies are also recorded on the medication administration record (MAR) chart. Receipts, administration and disposal of medications had all been recorded and signed for. Liquid medications had been dated when opened, as had any medication not supplied in the NOMAD cassette, which is good practice. Daily fridge temperatures and room temperatures were within safe range, and an air conditioning unit has been installed in the medications room to maintain the room temperature below 25˚centigrade in the hot weather. Controlled drugs are correctly stored and the administration records had been accurately completed. For one medication instruction the term ‘as directed’ had been used, and the need to ensure that accurate administration instructions are included for all medications was discussed. One weekly medication had not been administered and action was taken to address this finding. One medication found was not entered on the MAR chart and the registered nurse said that she would discuss this with the GP as the service user no longer required it. Medications are kept in the home for 2 weeks following the death of a service user, and are then disposed of. The home has the correct system in place for the disposal of all medications. The BUPA medications policy had been updated to reflect current legislation, and a copy of the updated documentation was available in the main office, and action was taken to provide up to date documentation in the medication room. The Deputy Manager had recently carried out a thorough medications audit and a new document for this has been introduced. The dispensing pharmacist had also carried out a recent inspection. Staff were seen to care for service users in a gentle courteous manner. Service users spoken with expressed their satisfaction with the home and said that they enjoy living there. Service users looked well groomed and clothing is individually labelled for each service user. Service users can bring in personal Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 11 possessions in line with health & safety. There was a good atmosphere throughout the home and service users looked well cared for. Clare House DS0000010928.V306491.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity input for the home is specific to the interests of the service users, thus ensuring their individual wishes are respected. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home has a full time activities co-ordinator. There is an activities room with evidence of many different activities being available to service users. A ‘Map of Life’ is completed with each service user, and this gives a life history to include family, work, leisure and social interests, and is used by the activities co-ordinator to formulate an activities programme to meet the interests and abilities of the service users. The activities co-ordinator maintains a daily record of each service users’ participation in activities, and then compiles a monthly report for each service user. Various activities were in progress, and it was clear that each service users level of ability is considered, for example, for board games, so that they are fairly matched. Some service users were watching quiz programmes on the TV, and were enjoying them. There was Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 13 evidence of several outings having taken place during the summer months, with future outings also planned. The activities co-ordinator plans activities for the weekend for service users who wish. Service users spoken to said that they enjoy joining in the activities, but if they choose not to join in then this is respected. It was evident that the activities provision plays a large part in the life of many of the service users, and that the activities co-ordinator is creative and works hard to provide a diverse mixture of activities to meet individual needs. There were several notice boards throughout the home containing useful information to include copies of the activities programme and notice of outings being planned. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made welcome at the home. Service users can choose to receive visitors in one of the day rooms or in the privacy of their own bedrooms. The home has leaflets for Age Concern Advocacy services on display on the notice boards in the home. The Registered Manager is very aware of the importance of providing this information for service users and their representatives. The food provision in the home is good. Service users spoken with expressed their satisfaction with the meals. The home has a 4 week menu, and a choice of meals is offered, with alternatives being available to meet the service users wishes. Service users choices for each meal are recorded and given to the kitchen staff. The Inspector viewed the lunchtime meal. Service users were socialising and staff were available to assist service users as required. The kitchen was clean and tidy and records were up to date. Information such as service users birthdays was displayed. Drinks and snacks are available throughout the 24 hour period. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure with timescales for action. A copy of the complaints policy is displayed on the notice boards. There had been one complaint received via CSCI since the last inspection and this had been appropriately managed. Relatives spoken with said that they are kept informed of their loved ones condition and if they have any concerns these are addressed promptly. The home follows the Hillingdon Safeguarding Adults procedures, and the home’s own POVA procedures dovetail with this documentation. Staff spoken with said that they would report any concerns, and were clear on the procedures to follow. Policies for the management of service user aggression and the management of service users monies are in place. There have been no POVA issues since the last inspection. Clare House DS0000010928.V306491.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Work is ongoing with redecoration and refurbishment of areas of the home to maintain an attractive and safe environment for service users to live in. The communal space provision is good, providing service users with areas to sit and socialise with other service users, staff and visitors. Equipment and storage facilities are available to meet the needs of the service users and the home. Bedrooms are personalised, thus providing service users with a homely environment to live in. Work has been done to upgrade the shower provision, thus providing service users with suitable facilities to meet their needs. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. Redecoration and re-carpeting had taken place along half of the ground floor corridor and the Registered Manager explained that the second phase is to be done in September 2006. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 16 There are plans to redecorate and re-carpet the first floor corridor in 2007. Some bedroom carpets had been identified for replacement, and bedrooms are redecorated as they become vacant. Two new fire partitions have been put in place by the lift areas on the first floor. Automatic closures activated by the fire alarm are in place on bedroom doors, providing service users with a safe option to have their door open if they so wish. There is a spacious dining room, plus three sitting rooms and an activities room for service users to utilise. There are also well-tended garden and patio areas. One service user who enjoys gardening has a room on the ground floor leading to the patio and has developed their own garden area. The furnishings are of good quality and there is evidence of redecoration in various rooms as they require it. The table linen looked attractive and thought had gone into the colour co-ordination in the dining room. One shower room has been refurbished and is now a wet room. This has provided a good assisted facility for service users to use. The hot water pipe leading to the shower was not guarded and confirmation that this has been addressed has been received by CSCI following the inspection. There is a second assisted shower plus three assisted bathrooms in regular use in the home. In addition the home has two further bathrooms, with assisted facilities that are useable but in need of modernisation, and the Registered Manager said that this was planned for 2007. All of the bedrooms have en suite facilities, and there are additional toilets situated near the communal areas in the home. There are designated sluice rooms on each floor, which are lockable. Hot water temperatures are checked every 6 months for wash hand basins and monthly for baths and showers. In vacant rooms, a system of weekly flushing of the water outlets in accordance with the homes legionella procedures needs to be introduced, along with the introduction of cold water temperature checks. The Registered Manager said that this would be addressed. There was evidence of chlorination of the water tanks in line with health & safety requirements for legionella control, last carried out in June 2006. Following the last inspection additional storage areas have been provided both in the home and also by the installation of a new shed in the garden. There were no issues with storage noted at this inspection. Moving & handling equipment is available to meet the needs of the service users. Grab rails are available in the toilet facilities. A call bell system is in place throughout the home and bells were answered promptly. The bedrooms vary in size and design, providing service users with individualised bedroom space. The bedrooms viewed were personalised and homely. All the beds in the home are adjustable. Suitable door locks are in place, allowing access to staff in an emergency. Service users can have their own door key unless they do not wish to. The double rooms are used for single occupancy, and would only be used as doubles for two service users who had expressed a wish to share, for example, a couple. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 17 The home was clean and smelled fresh throughout. The laundry room was clean and tidy, and systems for the management of soiled and clean laundry are in place. Part of the flooring needed replacing and this was discussed with the Registered Manager. The home has two washing machines, which include sluice programmes for soiled linen. There are two tumble dryers. Systems to store and deliver service users personal clothing back to their rooms are in place. Electronic disinfectors are situated in each of the sluice rooms. Updated policies and procedures for infection control were available and staff had signed to say they had read and understood them. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was appropriately staffed to meet the needs of the service users. Staff had received appropriate training to provide them with the skills and knowledge needed to meet the needs of the service users, thus maintaining good standards of care. Robust recruitment and vetting procedures are in place, thus safeguarding service users. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the service users. The staffing rosters identify that staffing levels are maintained and that cover is provided for any absences. Kitchen, maintenance, administration and domestic staff are employed in appropriate numbers to meet the needs of the home. New care staff undertake the BUPA induction training, which is in line with the Skills for Care core standards. Following this training, NVQ in care training is arranged. Three sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The Deputy Manager is responsible for ongoing staff training. Comprehensive records of training undertaken and planned were available, with evidence of Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 19 attendance. Staff spoken with said that there are good opportunities provided for training in various topics relevant to the needs of the service users. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Service users monies are well managed, thus safeguarding service users interests. Staff supervision sessions take place, providing a forum for individual discussion and reflection on practice. Systems for the management of health and safety are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and has completed the Registered Managers Award, NVQ level 4. The Registered Manager said that she periodically attends training days and courses in topics relevant to the service user group and her role. Staff spoken with said that the Registered Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 21 Manager is approachable and supportive. Service users and visitors also commented that the Registered Manager takes time to chat with them and address any queries they may have. The Registered Manager said that she received a comprehensive induction when she commenced her job, and has been well trained to fulfil her role. A comprehensive self-audit for quality and development is carried out annually. Each section is completed by the relevant head of department, and the Registered Manager then completes and implements an action plan for each section to show how any shortfalls identified are to be met. Regulation 26 unannounced visits to the home take place monthly, and a copy of the report is forwarded to CSCI. The Registered Manager has weekly Heads of Department meetings, and any issues are then cascaded down to each department. Separate meetings for the registered nurses and for the care staff are carried out every 2 weeks. The Registered Manager said that she has held service user meetings in the past, but has found that it is more effective to meet with service users individually or within the activities group. Comprehensive policies and procedures files are in place, and updates are received in line with changes in legislation and good practice guidance. The home has a bank account specifically for service users personal monies, for which a monthly statement is received. The homes administrator maintains very comprehensive, itemised records for each service users individual income and expenditure, thus providing a clear audit trail for all service users monies. A monthly statement is sent to the service users representative responsible for their finances to evidence all expenditure. Relatively small amounts of money are held on behalf each service user, and additional funds are requested as required. Records of all monies received on behalf of service users are maintained. The system of managing service users monies is robust and the administrator ensures records are well maintained. The administrator said that she received comprehensive training to provide her with the knowledge and skills to manage the finance system for the home. The Deputy Manager has been responsible for staff supervision. Records viewed evidenced that relevant staff had received training to be supervisors, and bi-monthly supervision sessions have been arranged and carried out for all staff. The supervision document encompasses current practice, training & development and any relevant issues to be discussed. Staff training records evidenced that staff had undertaken health & safety training to include fire safety, moving & handling, infection control, food hygiene and other related topics. Updates are ongoing to ensure all staff have undertaken mandatory training & updates. The servicing and maintenance records were viewed at random and those viewed were up to date. Risk assessments for equipment and safe working practices were in place, with the exception of those for the kitchen, and the Registered Manager said that this would be addressed. Policies and procedures for health & safety are in place, Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 22 and these are updated corporately in line with new legislation. Staff then read any updates and sign to say they have done so. Daily security checks of the building are undertaken. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 23 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 3 X 2 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 X 3 X 3 3 3 2 Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The administration instructions for each medication must be accurate and clear. The term ‘as directed’ must not be used. Medication must be administered as prescribed. Any omissions in administration must be clearly recorded, to include the reason for omission. All medications must be entered on the MAR chart. If a service user no longer requires a medication this must be discussed with the GP. A system for flushing water outlets in line with legionella prevention guidance must be put in place. (previous timescale 18/11/05 not met) Action must be taken to replace the section of missing flooring in the laundry room and to ensure the flooring is sealed and impermeable. Risk assessments for kitchen equipment and safe working practices must be in place. Timescale for action 30/08/06 2. OP9 13(2) 30/08/06 3. OP9 13(2) 30/08/06 4. OP21 13(3) 22/09/06 5. OP26 13(3) 01/10/06 6. OP38 13(4) 01/10/06 Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations It is strongly recommended that discussion take place between the home, the GP and the dispensing pharmacist to put a robust system in place to ensure that full administration instructions are provided for all medications. Clare House DS0000010928.V306491.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 DS0000010928.V306491.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!