Inspection on 30/08/07 for Clare House Nursing Home

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Nursing Home 24/07/06

Clare House Nursing Home 12/12/05

Clare House Nursing Home 30/08/05

Clare House Nursing Home 06/09/04

Clare House Nursing Home 22/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Clare House Nursing Home 36 Hersham Road Walton on Thames Surrey KT12 1JJ Lead Inspector Lesley Garrett Unannounced Inspection 31st August 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clare House Nursing Home DS0000017598.V348869.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 Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clare House Nursing Home Address 36 Hersham Road Walton on Thames Surrey KT12 1JJ 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) 01932 224881 01932 252539 gilberr@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Physical disability (PD). The maximum number of service users to be accommodated is 32. Date of last inspection 24th July 2006 Brief Description of the Service: Clare House is an attractive Tudor style home situated in a residential area of Walton-On-Thames. It enjoys the benefit of a pretty, secluded garden, which is accessible to all service users. There are three sitting rooms, a conservatory and a large dining room, all of which have a homely atmosphere. An activities room offers a variety of interests and personal hobbies are encouraged. The home is owned by BUPA who are the registered providers. The home offers nursing care to 32 older people. Fees range from £700 - £1050 per week. This fee does not include newspapers, hairdressing, chiropody, manicures or physiotherapy. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 1100 and was in the service for five hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. We looked at the home’s records and completed a tour of the building. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The home was asked to complete an Annual Quality Assurance Assessment by the Commission and this has assisted with this site visit and report writing. The registered manager has recently moved to another BUPA home and had informed CSCI by letter of her resignation. The current deputy manager is the acting manager and for the purposes of this report she will be referred to as the deputy manager throughout this document. What the service does well: The home was asked in their AQAA what they feel they do well and it stated that they formally involve the people who use the service in developing the service and that they are consulted about what they do. All people who use the serviced have the benefit of a pre-admission assessment and this is evidenced the homes new care planning documentation, which was of a high standard. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 6 Activities are varied and comments received demonstrated that they are also enjoyed. The menus we observed showed us that the home has a good variety of food and the people who use the service told us that they enjoyed their meals. One individual told us that staff had been good helping her to find the food that she could eat following a serious illness. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. People who use the service can be assured that any complaint will be listened to and acted upon and all staff has safeguarding adults training. The home is about to undergo a major refurbishment programme and all people who use the service and their relatives have been consulted. 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. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000017598.V348869.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 Nursing Home DS0000017598.V348869.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): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All people who use the service have a pre-admission assessment and are confident that their needs will be met. The home does not provide intermediate care beds. EVIDENCE: The deputy manager stated that herself or the senior nurse carry out all preadmission assessments prior to anyone moving into the home. We sampled three individual plans of care and found these assessments to be in place. The deputy also said that following admission another assessment takes place to clarify the findings of the initial assessment and this allows procedures to change if needed. It was also stated that care plans are then generated from this assessment. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 10 Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 11 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): 7 8 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service have individual plans, which reflect the care and support they require and their health care needs are fully met. The medication policies and procedures that are in place and implemented by staff protect service users. The privacy and dignity of the individuals are respected. EVIDENCE: We sampled three personal care plans and found them to contain assessments of each individual’s needs, risk assessments and evidence that they are reviewed every month. The completed AQAA stated that people who use the service are supported to care for their own personal hygiene needs and that the home has access to company specialists in this field of care planning and can be consulted for advice and support at any time. We also observed evidence that the people who use the service or their relatives had also been consulted. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 12 The deputy manager stated that the home has the support of a local General Practitioner (G.P.) who visits every week and if required whenever they are called. People who use the service can also retain their own G.P. if all parties are agreeable. The AQAA states that people who use the service are registered with a G.P. of their own choice. It was also stated that the opticians, dentists and chiropodist are also regular visitors. The home uses a local pharmacy for the supply of their medicines. The AQAA states that the home has recently updated the medication policy and meets the criteria of the National Minimum Standards, guidance from the Nursing and Midwifery Council and The Royal Pharmaceutical Society. This policy is kept on the medication trolley. The nurses audit the medicines every week and this includes the controlled drugs. One medication administration record sampled stated that an individual self medicates some of their medicines and a risk assessment was in place for this individual. The home has a privacy and dignity policy but they also use the policy document called ‘Behind Closed Doors’ which has been written by a national organisation, which promotes privacy when using toileting facilities. All staff have read this document and the subject is always referred to during the induction of new staff. One survey returned to us by a relative said ‘the nursing side is carried out with good humour and sensitivity which helps patients maintains their dignity’. Another individual told us that ‘the staff is very good at maintaining my dignity’. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 13 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): 12 13 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to exercise choice and control in all that they do and the food is of a good quality. EVIDENCE: The home employs an activities organiser and an activity helper so activity is available in the home six days a week. Training is available to them and this happens at least twice a year and meetings are held monthly. People attending the activities forums consist of the manager, the co-coordinator, people who use the service and relatives. The deputy stated that as a result of these meetings and suggestions made a new activity has been introduced and that is an organisation that can bring animals to the home. A programme of activities available is displayed and a survey form returned stated ‘the activities are good and they go on outings and arrange entertainers’ and ‘relatives and friends are included in the homes events’. Other comments received states ‘ choice of activities are available but there is also a private room where she can follow her own interests’, Two local churches visit every week and a church service is held every month. The deputy stated that other denominations can be catered for and the people Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 14 who use the service have their religious beliefs documented in the individual care plans. The deputy manager stated that visitors are welcome at any time and on the day of the visit we observed visitors coming in and out of the home. One visitor stated that ‘the home was wonderful and the care received by her mother was excellent’. Choice is given to all people who use the service I everything that they do the deputy manager stated. They chose when to get up and when to go to bed. One person who uses the service told us that she had made a choice not to use a special mattress that the home had provided for her to help with her skin integrity. She stated that she knew the possible consequences of this action but stated that her quality of life would be better without it. We observed that this had all been documented in the care notes. We met with the chef on the day of the visit and observed the people who use the service during lunchtime. One person stated ‘the foods god here and I have just really enjoyed my lunch’. The deputy manager explained that the chefs who work for BUPA write the menu plans using a points system to ensure that all service users get a nutritious well balanced diet. The Environmental Health Officer had visited recently and had awarded the home an excellent and the chefs and kitchen staff was all very proud of this achievement. Clare House Nursing Home DS0000017598.V348869.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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are protected by the homes complaints policies and safeguarding procedures. EVIDENCE: The deputy manager stated that the home keeps a complaints and compliments log and she had received three complaints since the last inspection, which have both been resolved. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. We observed that the home had also received many more compliments. The home has the local authorities procedures for safeguarding adults and the manager stated that the home follows these procedures. The deputy manager stated that the home has had no referrals under these procedures since the last inspection. Documentation observed by us demonstrated that staff has had training in safeguarding adults and this takes place regularly. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a well-maintained environment, which was clean and hygienic. EVIDENCE: The home is about to undergo a total refurbishment programme and the deputy manager stated that all people who use the service and their relatives have been consulted. The deputy stated that a few people who use the service have been moved, with their consent, to another BUPA home and all admissions have been suspended until the work has been completed. The home employs a full time maintenance person and has recently employed another person to help during this period of maintenance to support him. The home was clean and tidy and the AQAA told us that the home uses a microfibre cleaning system combined with effective cleaning regimes keeps the home clean and odour free. New housekeeping staff has recently been Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 17 employed and they have all enrolled with a local college to do their National Vocational Qualification (NVQ) in cleaning. The laundry is small but we were told that the laundry assistant has developed systems to ensure that the clean and dirty laundry is kept separate. All staff that uses the laundry has infection control training the deputy stated. It was observed that there were plenty of facilities for hand washing around the homes. Clare House Nursing Home DS0000017598.V348869.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. 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. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of people who use the service. EVIDENCE: In conversation with the manager and observation of the staff rota it was noted that the home has sufficient numbers of staff to meet the needs of the people who use the service. Comments received by two people who returned survey forms stated that they thought staffing needed to be increased at weekends. The rota did not show that numbers fell at weekends and the deputy stated that there is always someone on call for staff to refer to if needed. The deputy also stated that numbers of staff could be increased if the dependency levels increase. The rota showed that the deputy has supernumerary hours and also the senior clinical nurse. NVQ training is in progress for the care staff and when the current round of training is complete the home will have 72 of their staff trained. The deputy also ensures that the rota contains a mix of skills for all staff on each shift. We observed three recruitment folders and found that all the necessary documentation to enable the home to employ staff were in place. The AQAA stated people who use the service are also invited to participate in the Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 19 interviewing process. The home also has the advantage of a team of bank staff, which mends that they do not have to use agency staff. The deputy told us that she has a training programme for the home which clearly identifies training that has taken place and further training requirements of the staff. Mandatory yearly training is delivered in the home, which includes fire awareness, safeguarding adults, food hygiene and manual handling. All staff have completed an introduction to dementia training package. Clare House Nursing Home DS0000017598.V348869.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness, has effective quality assurance systems developed by a qualified competent manager. EVIDENCE: The registered manager has recently left the home to take up a post in a BUPA home near to where she now lives. The deputy is now the acting manager and has been given supernumerary hours until a new manager is recruited. Another manager from a local home and the organisations operations manager support the deputy. One relative that was visiting on the day of the visit told us that he had concerns about the lack of manager in the home again and that this had happened during a refurbishment programme. This concern was Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 21 discussed with the deputy for her to consider the best way of dealing with any concerns within the home during this time. The home has regular quality audits and the BUPA customer satisfaction survey was undertaken in December 2006. The deputy told us that the home has devised questionnaires to cover care and activities, laundry and housekeeping and menus and the views of the people who use the service will be sought every three months. Nominations are also received from individuals about the homes staff and awards can be given in recognition of the work\ that they do for them. Resident and relative meetings are held every three months and minutes are kept. Results from any surveys or audits undertaken in the home can be fed back during these sessions. The home has a bursar who manages any personal allowance account for people who use the service. Receipts are kept and summaries of these accounts are given to the individuals or their relatives/representatives. The bursar is able to withdraw cash if requested by an individual. The completed AQAA demonstrated to us that all the necessary health and safety checks had taken place and no certificates were outstanding. The home has a health and safety committee which meets every three months and minutes are kept of these meetings. Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 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. 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X X 4 Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clare House Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Nursing Home DS0000017598.V348869.R01.S.doc Version 5.2 Page 25 - 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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