Inspection on 31/01/07 for Claremont House

This inspection was carried out on 31st January 2007.

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

Claremont House 22/09/06

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 31st January 2007 08:10 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.V322897.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.V322897.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.V322897.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 22nd September 2006 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 4 January 2007 that fees are £508.27 per week. Additional charges include hairdressing, private chiropody, toiletries, 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.V322897.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 31 January 2007. The inspector arrived at the home at 08:10 am and left the home at 3:15 pm. This visit was the second at Claremont House 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, lunch being served, and how staff and service users interacted through the day. Prior to the visit, ten service user questionnaires were sent to Claremont House to obtain service users’ views about living at the home. Five completed questionnaires were returned. Some service users in the home are very frail and may have difficulty completing a questionnaire. Of the five questionnaires returned, the service users’ relatives had completed three. Relative surveys were sent out to ten of the service users’ relatives or friends. Two GPs attend the home and questionnaires were sent to them. When the inspector wrote this report, none of the relatives had responded. Both GPs had completed and returned questionnaires. 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. Since the home’s first inspection in September 2006, the standard of care and overall safety measures in the home have improved greatly. The home’s manager and her staff should be complimented on the changes made and the work carried out to make improvements at this relatively new home. The only requirement made following this visit relates to the work required to fit alarms to service users’ bedroom doors. This work was required to ensure that service users do not inadvertently wander from their bedroom into other service users’ bedrooms, especially during the night. One such incident has occurred since the last visit when the requirement was originally made. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 6 However, the delay in fitting these alarms is outside of the manager’s control and rests with Kirklees Metropolitan Council as the registered providers. What the service does well: What has improved since the last inspection? Wherever possible, and before a service user is admitted to the home, a member of staff carries out a pre-admission assessment. This helps to ensure that Claremont House and the staff at the home are able to meet the prospective service user’s needs. Work has been carried out on care plans. Care plans are individualised, identify service users’ health and welfare needs and advise staff how these needs are to be met in the home. Risk assessments are completed fully and reviewed monthly. Increases in staffing levels and improvements to the routines in the home mean that service users’ privacy and dignity are now more fully maintained Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 7 and promoted by staff. The home has a calmer atmosphere and is a more pleasant place to live and visit. Activities are now being offered to service users on a regular basis. However, feedback from a relative indicated this could be further improved. Meal times are now generally organised, calm and pleasant for service users and staff. Work has continued to develop Claremont House’s homely atmosphere. Pictures have been provided in communal areas and the garden has been planted with shrubs. General cleanliness in the home is good and the unpleasant odour in two rooms identified at the last inspection has been addressed. Staffing levels in the home have been increased, although two relatives who returned questionnaires indicated that, in their opinion, there are times when staffing is insufficient or that staff are “over stretched”. Recruitment files are now kept in the home and contain all the relevant checks and references needed to help protect service users from prospective employees who might be unsuitable to work with vulnerable elderly people. Quality assurance and monitoring has progressed in the home and shows that service users, relatives and visitors are being asked for their opinion about the service and how it might be improved. The majority of health and safety issues identified at the last visit have been addressed. What they could do better: Although activities are now offered to service users, feedback from relatives indicates this could still be improved upon. The manager should implement her plans to offer outdoor activities and look at ways of ensuring all service users have access to activities of their choice. Staff training is given priority in the home, however the home has below the recommended 50 of care staff with a National Vocational Qualification (NVQ) at level 2 or above. Work should continue to gain 50 of care staff with this level of training. As mentioned at the beginning of this summary, one requirement remains outstanding. This requirement is to fit monitors to all the service users’ bedroom doors to help prevent service users wandering into other service users’ rooms. This must be addressed as a matter of urgency. Following this visit, a written assurance was received from Kirklees Metropolitan Council advising monitors will be fitted at Claremont House by the 23 February 2007. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 9 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.V322897.R01.S.doc Version 5.2 Page 10 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. Standard 6 is not applicable. Where possible, no service user moves into the home without having had their needs assessed and been assured their needs can be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection, a recommendation was made that, wherever possible, a suitably trained member of the care team should carry out a pre admission assessment. This assessment of the prospective service user helps to ensure that the home and the care staff at the home are able to safely meet the service users’ care and welfare needs. During this visit, the manager advised that this process is now being carried out on all planned admissions. The home does have some emergency short Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 11 stay admissions and in these cases it is not feasible to carry out a pre admission assessment. However, the pre admission assessment documentation is completed as soon after admission as possible. This was confirmed when a sample of care records was audited. There was clear written evidence to show assessments had been carried out and, although service users were unable to confirm visits had been carried out, one relative indicated a pre admission had been completed before their relative was admitted to the home. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 12 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 and 10. Service users’ health, personal and social care needs are set out in an individual plan of care. Suitable risk assessments are carried out and monitored. Service users are able to make decisions about their lives with the support of staff. Medications are managed safely. Service users are treated with respect, and staff maintain their privacy and dignity. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: After the last visit, the registered manager and provider were required to improve the information held in care plans and ensure risk assessments were fully completed. This work has been done. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 13 New care plans have been developed and these are of a good standard. Each service user has a care plan which give members of staff clear and individual information about the service user, their strengths and weaknesses and how there needs are to be met whilst in the care home. A sample of four care records was audited during this visit and these contained fully completed risk assessments that have been reviewed at least monthly. A sample of three medications was audited during this visit. The management of medications is good. Records are clear and accurate. Medications audited tallied with the records in the home. At the last visit, the inspector was concerned about the way service users were being managed, particularly at meal times. A requirement was made asking the registered manager and provider to ensure service users’ privacy and dignity be maintained at all times. This requirement has been met. Routines in the home have been reviewed and changed. Staffing levels have been increased. Generally, the home had a much calmer and relaxed atmosphere. More importantly, service users were relaxed, comfortable and interacting with one another in a positive manner. Service users were sitting chatting to one another, some were taking part in activities. During the visit, the mealtime was calm and organised. Members of staff were able to spend time with service users, prompting and assisting them in a very sensitive manner. This is a marked improvement from the last visit. Service users engaged readily in conversation with the inspector and some service users initiated conversation. In discussion with one service user the inspector remarked how well they were looking. The service user replied, “It’s all credit to the family with whom I am staying”. The inspector also spoke to six members of staff. They too reported improvements in the care and routines in the home. At the last visit, two bedrooms were identified as having severe, offensive odours. The odour problem in those two rooms is now being managed appropriately. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 14 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 and 15. Service users’ social, cultural, religious and recreational needs are being met; they are helped to maintain contact with their families and the local community. Service users are able to exercise some choice and control over their lives. Meals provided are varied. Meals are served in a pleasant environment and service users who need support receive the assistance they require. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feed back and evidence from the last visit showed that there was little in the way of activities being offered in the home. A requirement was made for the registered manager and provider to ensure activities were offered and to provide dedicated activity hours. This requirement has been met. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 15 The home now has an activities organiser who works eighteen and half hours per week. At the time of this visit, the activities organiser was seen organising group activities such as a game of dominos with four service users and was talking on a one to one basis with other service users. The home now has a motivation group and a pat-a-dog scheme visits. Two volunteers have been recruited and are to work on a one to one basis with some service users, and organise a regular tea dance and coffee morning. Staff said that a trip to a local pantomime had also been arranged. A record of the activities offered is maintained and the initials of those service users who have taken part are recorded. A church minister now visits regularly. One relative commented in their returned questionnaire that activities have been offered since last year, however in their opinion there were still insufficient regular activities offered to service users. This was discussed with the manager and staff. The manager advised further activities are planned and equipment has been ordered to furnish the garden and provide equipment and games to encourage activities. It is recommended that activities be monitored in the home to ensure all service users have equal opportunity to take part in activities of their choice. It may help with the monitoring of activity levels where individual records kept on each service user’s file and reviewed monthly. Relatives confirmed in returned questionnaires that they are made to feel welcome. One stated, “I am always made to feel welcome by all.” Service users are able to exercise choice and control over their lives. Care plans clearly document service users’ preferred routines and preferences, likes and dislikes about their routine, meals and menus and some activities. On the day of this visit members of staff were seen and heard to offer service users choices about where they spent their day, whether they wanted to take part in activities and what they wanted to eat at meal times. Service users were asked if they preferred to listen to the radio or watch the TV. The radio programme playing was appropriate to the service users, rather than the staff. Service users who spoke to the inspector during this visit all said the meals were good. The meal being served during the visit was appetising and the menu offered was varied. Staff assisting and supporting service users at meal times showed skill and patience, encouraging service users to sit at the table and to maintain their independence. Staff constantly offered choices during the meal ensuring service users ate adequate amounts. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 16 Service users’ records show that nutritional intake is monitored and a regular check is made of service users’ weight to ensure their weight remains appropriate. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 17 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 and 18. Service users and their relatives and friends are confident to make complaints and that these will be listened to and taken seriously. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager advised that the complaints procedure has recently been reviewed and of a copy of the new procedure has been sent out to all relatives. The three surveys returned by relatives and the two from service users indicated they know how to make a complaint. Two complaints have been made to the home since the last visit. A record of the complaints and the action taken to address the issues raised was available. Service users are generally protected from abuse; however there have been incidents of abuse between service users. Members of staff have clearly recorded and reported these incidents appropriately. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 18 All staff in the home have had training about abuse and the protection of vulnerable adults. Steps have been taken to reduce the incidence of service user to service user abuse. Staffing levels have been increased during the day and a dedicated activity organiser has been provided to help provide activities for service users. Routines in the home have been reviewed and changed. The number of incidents is declining. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 19 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 and 26. Service users live in a safe, well-maintained environment. The home is clean, generally pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is modern, well equipped and purpose built. Since the last visit, pictures have been hung on the corridor walls to help promote a homely feel. The manager hopes to provide accessories to the bathrooms to help them feel less clinical. Service users’ rooms are pleasant and some are personalised by the service users. Service users were pleased to show the inspector their rooms and were pleased and proud of the new facilities. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 20 Generally the home was clean and tidy during this visit. The two rooms identified as having unpleasant odours at last inspection have been addressed. However, one relative said in their questionnaire that the home “has bad odours now and again”. This was discussed with the manager. At present, there is a problem with some of the drains in the home and two rooms were particularly smelly. However, service users have temporarily been moved from these rooms and Kirklees Metropolitan Council is arranging for the problem to be investigated and remedied as soon as possible. It is thought the problem is a “ teething problem” of the new building. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Suitable numbers of staff are employed. Members of staff receive induction and foundation training and are generally competent to work in the home. Staff recruitment policies and records protect service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last visit to the home, requirements were made regarding staffing levels as the inspector felt that the home was under staffed. Following this, staffing levels have been increased. Dedicated activities organiser hours have been provided and cover in the laundry has been extended to seven days a week. Care staff hours have also been increased. Staffing levels now include the manager who usually works Monday to Friday 9-5 and whose hours are supernumerary. During the morning shift there is one care co-ordinator, two team leaders, and one carer per unit plus two “ floating” carers who provide support to the carers on the units, thus making a total of nine care staff. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 22 In the afternoon, there is one care co-ordinator, one team leader and one carer on each of the unit plus two “floating” carers, making a total of eight staff. At night there are three wakeful carers on duty. The manager and members of staff reported that these increases have had a positive effect on the care provided and on the work environment. However, at times, because of the service user group and some emergency admissions, the home can be very busy. Two relatives commented in returned questionnaires that, “The staff at Claremont are fantastic (care staff) but they seem to be under great pressure due to staff shortages”, and “not enough staff in the home, they are over stretched at times”. The registered manager and provider should continue to keep staffing levels under review to ensure that there are sufficient staff on duty to safely meet service users’ needs. There is a commitment to training and, at present, the home has 43 of its care staff trained to National Vocational Qualification (NVQ) level 2 or above. A further seven staff are working toward NVQ level 2 and one toward level 3. NVQ training should be encouraged and continue until a minimum of 50 of the care staff have NVQ level 2 in care or an equivalent qualification. This is to promote good standards of care for service users. During this visit a sample of three care staff recruitment records were audited and contained the required information, references and checks. Since the last visit, a varied programme of training has been offered to members of staff. The members of staff who spoke with the inspector during this visit confirmed that they had been able to attend several training sessions and were booked to attend further courses. Training covered since the last visit includes fire, movement and handling, food hygiene, dementia care, managing challenging behaviour, adult protection, health and safety and first aid. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Service users live in a home with an experienced and competent manager of good character. 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 this outcome area is good. This judgement has been made using available evidence including a visit to this service. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home continues to be managed by an experienced manager of good character. Members of staff who spoke to the inspector during this visit acknowledged the hard work the manager and the whole of her staff team have put into addressing the many issues identified at the last visit. All the staff showed an excellent knowledge of the care needs of service users and demonstrated skill in managing and caring for service users with dementia. Quality assurance measures have been implemented and the staff advised that questionnaires have been sent out to relatives and to staff who work in the home. As part of the home’s quality audit, and so that service users, relatives and visitors can comment and influence the way the home is managed and run in the future, questionnaires have been sent out. The manager is making arrangements to ensure the results of these surveys are available to visitors in the entrance of the home. Monthly management visits have been carried out and a report produced and forwarded to the Commission for Social Care Inspection as required following the last visit. 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 continues to be a well-equipped care home. Equipment and fittings are new and within manufacturers’ warranties. At the last visit several health and safety issues were identified. The majority have now been addressed. Due 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 last visit, some did not have a key. This has now been addressed and all the staff on duty at the time of this visit had a key on their person. As required following the last visit, the garden area has now been made safe and has been planted with shrubs. It now offers a safe and attractive facility for the service users, relatives and staff at the home. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 25 At the last visit information received in Regulation 37 notifications, and discussions with staff during the visit, indicated that service users were inappropriately entering one another’s rooms. This risk was 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. A requirement was made that all bedroom doors be fitted with a monitor to alert staff when a service user has opened their bedroom door. This has not yet been addressed. Since the last visit, a serious incident occurred when one service user entered another service user’s room. Members of Kirklees’ estates department spoke to the inspector during this visit and advised that this work had not been done as to work on the electrical system would affect the warranty provided by the company who built Claremont House. The estates manager could not give any firm date for the work to be completed. Since the visit, the responsible individual from Kirklees Metropolitan Council has provided written assurance that monitors will be fitted by 23 February 2007. It remains a requirement of this report that further door monitors be provided as a matter of urgency, to help prevent further incidents occurring. Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 26 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Claremont House DS0000067656.V322897.R01.S.doc Version 5.2 Page 27 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 OP38 Regulation 13(4) Requirement Sufficient monitoring equipment must be provided in the home to adequately guard against service users inappropriately entering one another’s bedrooms during the day and night. Timescale of 16/10/06 not met. Timescale for action 28/02/07 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 OP12 Good Practice Recommendations It is recommended that activities be monitored in the home to ensure all service users have equal opportunity to take part in activities of their choice. It may help monitor who takes part in activities if the activity record is held in each individual service users’ care records, so that it can be reviewed monthly. Work should continue to obtain the recommended level of 50 of care staff with NVQ level 2 training or equivalent. This is to help ensure that staff are trained and skilled to provide care to service users. DS0000067656.V322897.R01.S.doc Version 5.2 Page 28 2. OP28 Claremont House Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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