Inspection on 22/09/06 for Claremont House

This inspection was carried out on 22nd September 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

Claremont House 31/01/07

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Fern Lea

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

CARE HOMES FOR OLDER PEOPLE Claremont House Brighton Street Heckmondwike West Yorks WF16 9EU Lead Inspector Sally McSharry Key Unannounced Inspection 22nd and 28th September 2006 08:15 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 Claremont House DS0000067656.V306903.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. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Claremont House Address Brighton Street Heckmondwike West Yorks WF16 9EU 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) 01924 325659 01924 325660 www.kirklees.gov.uk Kirklees MC Miss Angela Teal Care Home 40 Category(ies) of Dementia (40), Dementia - over 65 years of age registration, with number (40) of places Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users should be admitted that are under 55 years of age. Date of last inspection N/A Brief Description of the Service: Claremont House is a two-storey care home, providing accommodation and personal care for up to forty service users with dementia type illnesses. The majority of service users are elderly and are aged over 65 years, however the home is able to care for service users from the age of 55 years. Claremont House was purpose built and registered with the Commission for Social Care Inspection in May 2006. The home provides single bedroom accommodation. All bedrooms have full en suite facilities. The accommodation is provided in four, 10-bedded suites. Each suite has a kitchenette, open plan dining and lounge areas and assisted bathing and toilet facilities. There is a communal meeting room, hairdressing facilities and a separate smokers’ lounge. The home has a good-sized, enclosed garden and service users on the ground floor have direct access from the dining areas to the garden. Claremont House is situated on Brighton Street in Heckmondwike, a residential area within 5-10 minutes’ walk from the town centre. The provider informed the Commission for Social Care Inspection on 22/09/06 that fees are £508.27 per week. Additional charges include hairdressing, private chiropody, newspapers and magazines, insurance for personal belongings and taxi fees, if required. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home which was carried out by an inspector on 22 September 2006. The inspector arrived at the home at 08:15 am and left the home at 3:30pm. A further visit was carried out on 28 September 2006 to Oldgate House in Huddersfield to check staff members’ recruitment files and records. This inspection is the first at Claremont since its registration in May 2006. During this visit the inspector spoke to some of the service users, some of the staff and the home’s management. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a brief tour of the building. The inspector observed some of the routines in the home, breakfast and lunch being served, and how staff and service users interacted through the day. Prior to the inspection, ten service user questionnaires were sent to Claremont House to obtain service users’ views about living at the home. No completed questionnaires were returned. Some service users in the home are very frail and may have difficulty completing a questionnaire. Relative surveys were sent out to ten of the service users’ relatives or friends. One GP surgery attends the home and questionnaires were sent to them. Two health and social care professionals that have contact with the home and service users were also sent a questionnaire. When the inspector wrote this report, four of the relatives had responded. A response had been received from the GP surgery. Neither of the health and social care professionals responded. Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home and a pre-inspection questionnaire completed by the provider and manager. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Where possible, staff from the home should carry out a pre-admission assessment to ensure the staff and the home are able to meet the prospective service user’s needs. Care plan documentation and risk assessments must be fully completed and give clear, detailed and specific advice to staff about the service users’ needs and how they are to be met in the home. The dignity of some service users is being compromised in that two rooms had strong offensive odours despite efforts to address this. Service users were being accommodated in these rooms. Further action must be taken to ensure these rooms are free from odours. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 7 Owing to the availability of staff, and the way in which meals were being served, at times some service users were observed eating from other service users’ plates. This must be addressed to maintain service users’ dignity. Some activities are offered in the home; however, the level of activities must be increased. Since the home opened in May 2006 there has been a high incidence of service user to service user abuse. Action must be taken to protect service users and reduce the number of incidents. Although the home is newly commissioned, the garden has not been fully planted or maintained. There has also been an incident in the garden and, following this, it was identified that a safety fence be fitted; as yet this has not been addressed. Taking into account the number and needs of the service users, the layout of the building and the observation made by the inspector during the visit, further care and support staff are required to provide care to service users. Therefore, a review of staffing levels must take place. Quality assurance and monitoring is progressing in the home. It is recommended that this be monitored to ensure it is effective and to ensure identified issues and addressing promptly. Copies of the monthly management report carried out by the registered provider must be forwarded to the Commission for Social Care Inspection on a monthly basis. All staff in the home must carry on their person the key required to activate the fire alarm system. 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. Claremont House DS0000067656.V306903.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 Claremont House DS0000067656.V306903.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Although the home obtains community care assessments, they do not carry out there own pre-admission assessment. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: When auditing records there was no evidence of pre-admission assessments having been carried out by staff from the home. Information about the prospective service user is obtained from the community care assessment and care plan. However, a fuller assessment is needed and should be carried out, where possible, by a trained member of staff from the home. This should take into account whether the home has sufficient numbers of appropriately skilled staff to meet the service user’s needs and whether appropriate equipment is available, bearing in mind the individual service user’s needs and those of the existing service user group. The registered manager has no autonomy over the decision to admit service users to the home. The inspector is concerned as this means that, although Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 10 she is registered and deemed to be responsible for the home, the manager has no control over admissions to the home. Current practice means that, if there is a gap in the information provided on a community care assessment or the assessment is out of date, the home is unable to adequately prepare for a service user’s admission. An example of this was seen during the visit when a new service user was admitted to the home. The community care assessment failed to clearly identify that the service user was being cared for at home on a specialist mattress. Staff in the home and the relatives of the service user had to make arrangements for the mattress to be brought to Claremont House from the service user’s home. In this instance, the service user’s relatives were able to transport the mattress. A suitably trained member of staff should, where possible, carry out a preadmission assessment (as detailed in Standard 3 of the National Minimum Standards for Older people) before any service user is admitted to the home. Service users are admitted to the home with diverse needs and from a range of social and cultural backgrounds. Claremont House does not provide intermediate care at the moment. Claremont House DS0000067656.V306903.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Service users’ health, personal and social care needs are set out in an individual plan of care. Not all service users have had risk assessments completed. Service users are able to make some decisions about their lives with the support of staff. Medications are managed safely. Service users are treated with respect and their privacy is maintained. However, on occasions, service users’ dignity is being compromised. Quality in the outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records of four service users were checked. There is valuable information in care records about the individual service user’s past life and social history. Care plans reflect service users’ individuality. Care plans are developed over time and are based on the service user’s strengths. However, not all the records checked had a full care plan in place and some care records had incomplete risk assessments, such as nutritional assessments, diabetes assessment and oral care assessments. All service users must have a complete Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 12 care plan, which advises staff how the service user’s needs are to be met in the home. Risk assessments must be completed. This is made a requirement of this report. A sample of medications was audited and was found to be correct. The management and recording of medications is clear and of a good standard. During the visit, and in conversation with service users, it is clear that members of staff help maintain service users’ privacy. Personal care is attended to discreetly and in private. Service users have their own rooms and these are locked when the service users are not in to prevent other service users entering accidentally. During this visit the inspector saw the dignity of some service users being compromised. Two bedrooms had severe odour problems and, despite efforts to address this, the odour remained. It is undignified to expect service users to sleep in rooms with such an offensive odour. The issue of poor odour management will be addressed in the environment section of this report. At mealtimes, the dignity of some service users was being compromised. The inspector observed lunch being served on one of the suites. There were not sufficient staff members available to assist. A carer and a member of the domestic staff were serving the meal from the kitchenette, trying to supervise and support service users and assist some service users to eat their meal. A team leader also joined the two members of staff to help. However, service users were unsettled and their behaviour disruptive. Two service users were observed eating from other service users’ plates despite the staff’s best efforts. This is not dignified for service users and unsatisfactory for staff. This issue will be addressed in the staffing section of this report. Claremont House DS0000067656.V306903.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users’ social, cultural, religious and recreational needs are not being fully met; they are helped to maintain contact with their families. The staff at the home are building links with the local community. Service users are able to exercise some choice and control over their lives. Meals provided are varied. Service users need further support to ensure they all receive the assistance they require. The dining environment does not provide a pleasant and relaxed atmosphere for service users. Not all service users are supported in a manner that promotes their dignity at mealtimes. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Throughout the visit, service users were seen wandering without occupation and altercations between service users occurred. At such time, the available care staff were fully occupied in providing care and support to other service users. At present, there are no dedicated activities hours or staff and care staff are fully occupied with providing personal care. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 14 There are plans to increase the activities offered in the home. At the moment arrangements have been made for a “Pat a Dog” scheme to visit the home regularly. Staff reported that service users are now remembering the dog and recognising him when he visits. Staff informed the inspector that arrangements are being made for an artist to come into the home and work with service users. Staff also plan to offer a regular “Tea Dance” and join in activities with another local care home. Staff also hope to set up the “League of Friends of Claremont House”. Staff reported that they are in the process of building links with the local churches. One service user regularly attends church, supported by their family. Hairdressing facilities and services are provided in the home and service users were seen enjoying a morning with the hairdresser. Daily activities hours must be provided to ensure service users’ social and cultural needs are met and to provide them with meaningful activities and this should help reduce any incidents between service users. There is open visiting at the home. Service users confirmed their relatives and friends are able to visit at any time. Relatives and friends advised in the returned questionnaires that they are made to feel welcome when visiting at the home. Service users are able to exercise some choice and control over their life in the home. Service users are able to choose when they get up in a morning and retire to bed at night. They are able to choose where they spend time in the home during the day. A choice of menu is available at each meal. During this visit, one service user was asking to walk into Heckmondwike to do some shopping. It was not possible to accommodate this request owing to staffing levels. Meals provided in the home are wholesome and the menu is varied. The meals being served during the visit looked and smelled appetising and service users said they were good. Meals are served from the kitchenettes on each suite. However, at breakfast time, owing to morning staffing levels breakfast is served on one ground floor and one first floor suite. This means service users from two of the suites have to walk across to another suite for breakfast. At lunch time, one of the domestic staff helps a carer serve and supervise meals. On the day of the inspector’s visit, the inspector watched lunch being served on one of the suites. The two members of staff serving the meal were attentive to service users. They tried to plate up and serve the meals promptly whilst supervising service users and assisting one service user with their meal. A third member of staff came to assist in the serving of lunch, however, because of the needs of the service users on that suite, two service users continued to wander and eat from other service users’ plates. This caused upset and agitation between service users on the suite and compromised service users’ dignity. Additional Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 15 staff are needed to assist. Staffing levels will be discussed in the staffing section of this report. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 16 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 and 18. Service users and their relatives and friends are confident to make complaints and know that these will be listened to and taken seriously. Service users are protected from abuse. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Relatives and visitors confirmed in returned questionnaires that they are aware of the home’s complaints procedure. The manager keeps a record of complaints made, the outcome of the investigation and any action taken as a result. Staff at the home have received adult protection training and are aware of the local policy and procedures. However, there has been a relatively high level of service user on service user abuse in the home, eighteen incidents having occurred since the home opened. Staffing levels, the routines in the home and the layout of the home must be reviewed. Service users must be protected and safe in the home. The registered provider and manager must look at ways of reducing the number of incidents to ensure service users are safe. Claremont House DS0000067656.V306903.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Although service users live in a new home, there are some safety issues. The home is generally clean and hygienic. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Claremont House is a purpose built care home, built and fitted to a good standard. Bedrooms are spacious and have excellent en suite facilities. However, some problems have come to light since staff and service users took over occupation of the home. One area of the garden slopes towards the shrubs and, in August, one service user became caught up in the shrubs. Following this incident, it was proposed the area of shrubs be fenced off to make the area safe. However, at the time of the visit the fencing work had not been addressed. Service users continue to have access to the unprotected area. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 18 Turf has been laid in the garden; however, the proposed flowerbeds are unplanted and unkempt. The garden should be maintained and provide an attractive area for service users to enjoy. Claremont House has a well-equipped laundry. Some laundry and domestic staff are provided. During this visit, two bedrooms were noticed to have strong unpleasant odours. Although these rooms have been cleaned thoroughly, the problem remains. Action must be taken to address the offensive odours identified. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 19 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 and 30. Suitable numbers of staff are not being provided to meet the needs of the service users. The staff receive induction and foundation training and are competent to work in the home. Staff recruitment policies and records do not fully protect service users. Quality in the outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: During the visit there were insufficient care staff on duty to meet the needs of the service users, bearing in mind the number and needs of the service users and the layout of the building. As previously stated in this report, the inspector felt there were insufficient staff supervising meals and providing activities. Feedback from three of the four relatives and visitors who responded to the questionnaire said they felt insufficient staff are on duty. One stated, “There isn’t enough staff to care. One care worker to look after 12 patients is not enough. I know the staff have complained but it falls on deaf ears. But should you want an office worker there are always plenty of them. You know the saying, too many chiefs not enough Indians.” Care staff are inappropriately carrying out some kitchen assistant and laundry duties. There are no laundry staff provided at the weekend. Domestic staff are also carrying out care duties and assisting in the kitchen despite outstanding cleaning duties such as managing rooms identified as having an offensive odour. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 20 A review of care staff levels, both during the daytime and at night, must occur to ensure sufficient care staff are on duty to meet the needs of the service users in the home. A review of domestic and kitchen assistant hours must occur to ensure dedicated kitchen and domestic staff are available to carry out these duties. A review of laundry assistant hours must occur to ensure dedicated laundry hours 7 days a week. Members of staff working in the home were seen to be competent and caring. Service users were relaxed and clearly comfortable with the care staff. Service users who spoke to the inspector, and comments received from relatives in questionnaires, indicated that staff are kind, caring and hard working. Staffing records show that staff are receiving induction training, training in movement and handling, fire safety, basic food hygiene and adult protection. Sixty five percent of care staff have National Vocational Qualifications to level 2 or above. Two inspectors audited a sample of thirteen recruitment records on 28 September 2006 at Oldgate House in Huddersfield. The sample covered thirteen Kirklees Metropolitan Council services and establishments. Records were generally of a good standard. However, three of the files did not have a CRB number recorded to evidence a check had been carried out. Two of those files did not have evidence that a CRB check had been carried out by Kirklees as the employer. Seven files did not include a recent photograph of the member of staff. Action must be taken to address this. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 21 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 and 38. Service users live in a home with an experienced and competent manager of good character. Action is being taken to ensure the home is run in the best interest of service users. Service users’ financial interests are safe guarded. The health, safety and welfare of service users and staff is not fully promoted and protected. Quality in the outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager of the home is experienced and of good character. The move to Claremont House has been difficult but service users, relatives and staff confirmed that Ms Teal is approachable and has worked hard to resolve issues. Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 22 Some quality assurance measures are beginning to be implemented and the staff advised that a questionnaire has recently been sent out to relatives and to staff who work in the home. Monthly management visits have been carried out and a report produced. However a copy of these reports has not been forwarded to the Commission for Social Care Inspection. It is a requirement of this report that a copy of all monthly management reports be provided to the Commission for Social Care Inspection. A sample of four service users’ finances was audited at the home. Records were clear; there were receipts available for goods and services purchased on the service users’ behalf. The amounts of money held on each individual’s behalf were checked and found to be correct. Claremont House is a well-equipped care home. Equipment and fittings are new and within manufacturers’ warranties. Owing to initial problems with the fire alarm system, some of the fire alarms are now activated by a key. This requires all staff to have a key on their person at all times. This ensures the staff are able to activate the alarm in the event of a fire. At the time of the visit, there were staff that did not have a key. It has been made a requirement of this report that all staff must carry a key at all times in order to activate the fire alarm and that confirmation be provided that West Yorkshire Fire Service have agreed the changes made to the alarm system. Information received in Regulation 37 notifications, and discussion with staff during the visit, indicates that service users are entering one another’s rooms. This risk is greater at night when only three staff are on duty and bearing in mind the needs of the service users and the layout of the building. Sufficient monitoring equipment must be provided in the home to adequately guard against service users entering one another’s bedrooms during the day and night. There are currently four door monitors available in the home. Forty pressure pads have been provided but these are only activated if the service user stands on the pad. It is requirement of this report that further door monitors be provided. An incident occurred in the garden in August where a service user became caught up in the bushes. The home carried out a risk assessment which identified that the area should be fenced to prevent this occurring again. At the time of the visit, safety fencing had not been erected around the bushes. This must be addressed. Claremont House DS0000067656.V306903.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 15(1) Requirement Timescale for action 14/11/06 2. OP8 12(1) & 13(1) 12 (4) 3. OP10 Care plans must provide clear information to staff about service users’ needs and how these are to be met by the staff in the home. All risk assessments in service 14/11/06 users’ records must be fully completed and reviewed monthly. The registered person shall make 16/10/06 suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. Action must be taken to address the strong offensive odour in the two bedrooms identified. Sufficient staff must be provided to ensure service users’ dignity is maintained at mealtimes. Dedicated daily activities hours must be provided to ensure service users’ social and cultural needs are met and in order to provide them with meaningful activities in order to reduce any DS0000067656.V306903.R01.S.doc 4. OP12 16 (1) (n) (m) 30/10/06 Claremont House Version 5.2 Page 25 5. OP18 13 (6) 6. 7. OP26 OP27 12(4) 18(1) 8. OP29 19 & Schedule 2 9. OP33 26 incidents between service users, which may occur owing to a lack of occupation. The registered person shall make 31/10/06 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Therefore, staffing levels, the routines in the home and the layout of the home must be reviewed. And the registered provider and manager must look at ways of reducing the number of incidents to ensure service users are safe. Action is required to address 16/10/06 severe offensive odours in identified bedrooms. 16/10/06 A review of care staff levels, both during the daytime and at night, must occur to ensure sufficient care staff are on duty to meet the needs of the service users in the home. A review of domestic and kitchen assistant hours must occur to ensure dedicated kitchen and domestic staff carry out these duties. A review of laundry assistant hours must occur to ensure dedicated laundry hours 7 days a week. Required pre-employment 30/11/06 checks must be carried out on all staff. Recruitment records must include a CRB check carried out by the current employer and a recent photograph. Until further notice a copy of the 16/10/06 management visits reports required under Regulation 26 of The Care Homes Regulations 2001 shall be sent to the Commission for Social Care Inspection on a monthly basis. A DS0000067656.V306903.R01.S.doc Version 5.2 Page 26 Claremont House 10. OP38 23(4) 11. OP38 13(4) 12. OP38 13(4) copy of all reports from May 2006 to date should be forwarded to the Commission for Social Care Inspection. All staff on duty must have a key 16/10/06 to fire alarm activation points and written confirmation must be provided to the Commission for Social Care Inspection that the fire service has agreed this system. 16/10/06 Sufficient monitoring equipment must be provided in the home to adequately guard against service users entering one another’s bedrooms during the day and night. The garden must be made safe. 16/10/06 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 OP3 Good Practice Recommendations A system should be implemented whereby suitably trained and qualified member of care staff at the home carries out a pre-admission assessment to establish whether the home is able to meet prospective service users’ needs. The proposed flowerbeds should be planted and maintained. Quality monitoring in the home should be monitored to ensure it is effective in identifying issues and addressing them promptly. 1 2 OP19 OP33 Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Claremont House DS0000067656.V306903.R01.S.doc Version 5.2 Page 28 - 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!