Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 24/01/07 for Claremont Nursing Home

Also see our care home review for Claremont Nursing Home for more information

This inspection was carried out on 24th January 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a good standard of information to assist the individual to make a choice of whether to move in or not. Residents are assessed before they move into the home. Residents said staff are very helpful when providing care. They treat them with respect.

What has improved since the last inspection?

Resident and relative meetings are being held regularly. Some areas of the home have undergone refurbishment.

What the care home could do better:

Although the overall care planning and risk assessments for residents was good, the registered manager must ensure that when an individual comes into the home with already identified care needs and risks, then these are provided for as soon as possible. The care plans and risk assessments must show evidence that the resident or their representative has been involved with developing them. Consent to medication is also needed. All medications that are administered by care staff need to be signed for. A number of concerns were raised with regards to the promotion of the residents` privacy and dignity. The manager must review the care staff awareness of this area and ensure that it is not compromised. The activities person must be provided with training that helps to ensure the activity needs of residents with dementia are being met. The systems used for ensuring residents receive a good standard of food must be reviewed as there were some residents unhappy with the standard provided. The system for recording complaints in the care home must be reviewed, as it was unclear whether the home was dealing with complaints as set out in the regulations. Improvement is needed with the way the home deals with information that should be referred to the adult protection unit. Some areas of the home`s environment are in need of refurbishment. Some carpets have been left to get into an unacceptable condition and must be replaced. There is evidence to show the staffing levels of the home are either inadequate or the working systems staff are adhering to are wrong. This needs reviewing by management. Improvements are needed with the recruitment of staff. The manager has not been getting the required information needed before an employee is able to work in the home. Improvement is needed with the provision of training to the care staff. Mandatory training is good but staff need training in specific areas of care need that are relevant to the resident group. The number of staff with NVQ Level 2 training must increase.All care staff must start receiving regular supervision to assist them with fulfilling their roles. The management systems and processes must be reviewed to ensure the home is meeting the National Minimum Standards for Older People. There are areas of health and safety within the home that are in need of improvement to ensure the risks to residents and staff are minimised.

CARE HOMES FOR OLDER PEOPLE Claremont Nursing Home New Street Farsley Leeds Yorkshire LS28 8ED Lead Inspector Sean Cassidy Key Unannounced Inspection 24th January 2007 10:00 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 Claremont Nursing Home DS0000045220.V316342.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 Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Claremont Nursing Home Address New Street Farsley Leeds Yorkshire LS28 8ED 0113 2360200 0113 2360472 clmont@aol.com 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) Park Homes (UK) Ltd Mrs Carol Prior Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (2), Terminally ill (1), of places Terminally ill over 65 years of age (1) Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD places are for specified service users only TI(E) place is specifically for named service user Date of last inspection 28th February 2006 Brief Description of the Service: Claremont is a converted, extended, detached property, situated near the centre of the village of Farsley. The home is close to local bus routes and within easy access of a mainline railway station and the main roads to Leeds and Bradford. The home was first registered in September 1991. Park Homes UK Limited owns it. Nursing care for up to thirty-seven older people is provided. Accommodation is offered in a combination of twenty-one single and eight double rooms; all bedrooms have en-suite facilities. Service users have a choice of two lounges, and there is a spacious dining room. Gardens are available consisting of lawns and an attractive enclosed garden to the rear, with level access from one of the lounges. Car parking is provided to the front of the property. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An Unannounced visit to the home was conducted by one inspector and lasted one and a half days. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. What the service does well: What has improved since the last inspection? Resident and relative meetings are being held regularly. Some areas of the home have undergone refurbishment. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 6 What they could do better: Although the overall care planning and risk assessments for residents was good, the registered manager must ensure that when an individual comes into the home with already identified care needs and risks, then these are provided for as soon as possible. The care plans and risk assessments must show evidence that the resident or their representative has been involved with developing them. Consent to medication is also needed. All medications that are administered by care staff need to be signed for. A number of concerns were raised with regards to the promotion of the residents’ privacy and dignity. The manager must review the care staff awareness of this area and ensure that it is not compromised. The activities person must be provided with training that helps to ensure the activity needs of residents with dementia are being met. The systems used for ensuring residents receive a good standard of food must be reviewed as there were some residents unhappy with the standard provided. The system for recording complaints in the care home must be reviewed, as it was unclear whether the home was dealing with complaints as set out in the regulations. Improvement is needed with the way the home deals with information that should be referred to the adult protection unit. Some areas of the home’s environment are in need of refurbishment. Some carpets have been left to get into an unacceptable condition and must be replaced. There is evidence to show the staffing levels of the home are either inadequate or the working systems staff are adhering to are wrong. This needs reviewing by management. Improvements are needed with the recruitment of staff. The manager has not been getting the required information needed before an employee is able to work in the home. Improvement is needed with the provision of training to the care staff. Mandatory training is good but staff need training in specific areas of care need that are relevant to the resident group. The number of staff with NVQ Level 2 training must increase. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 7 All care staff must start receiving regular supervision to assist them with fulfilling their roles. The management systems and processes must be reviewed to ensure the home is meeting the National Minimum Standards for Older People. There are areas of health and safety within the home that are in need of improvement to ensure the risks to residents and staff are minimised. 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 Nursing Home DS0000045220.V316342.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 Nursing Home DS0000045220.V316342.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): 1 and 3. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed before moving into the home and receive good information to assist their choice. EVIDENCE: Residents and relatives spoken to said they had enough information given to them when they arrived at the home. A Service User Guide is provided to residents when they arrive. The Statement of Purpose and Service User Guide are also made available to all at the entrance of the home. The Service User Guide does not include all the required information with regards to fees. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 10 All the files inspected showed each resident had been assessed prior to moving into the home. Claremont Nursing Home DS0000045220.V316342.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care documentation used helps to ensure staff are made aware of the care needs of the residents. Attention is needed to ensure the standard of privacy and dignity is improved. EVIDENCE: Several care plans were seen and the overall standard was good. Where a care need was identified a plan of care was in place to meet that need. This was also the case for risk assessments. Residents are risk assessed in areas such as falls, nutrition, tissue viability and continence. The nursing staff reviewed these documents monthly. Evidence was seen to show that when a resident needed to be reviewed by another health care professional then this was done. Two residents with Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 12 wounds had been referred to the tissue viability nurse. Another identified as losing weight had been referred to the dietician. Residents and relatives confirmed that other health professionals see them regularly and they were positive about the responsiveness of the staff group in this area. Staff have access to the care files and they confirmed that they do access them when they need to. One care file inspected showed a resident’s care needs and risk assessments had not been developed for three of days after admission. The home had previously identified care needs that placed that person at risk of harm. This omission placed this resident at possible risk and the manager acknowledged this and gave assurances that this would be discussed with the relevant staff. The care plans did not consistently show that the residents or their representatives are involved with the care planning and risk assessment process. Documentation is in place to do this but it was not completed in three care plans seen. Consent is not obtained from residents to allow the home to look after and administer their medications. The manager said this will be reviewed. The home has a medication policy, which includes a policy for selfadministration. Two residents said they were asked if they wished to self medicate when they were admitted but they declined. This is good practice. Medication charts were randomly sampled. Two charts had unexplained omissions of nurse signatures. The nurse on duty at the time said that these medications had been given but had not been signed for. This is poor practice. Residents were very complimentary about the staff group. They said they were helpful and polite. They were observed to knock on resident doors before entering and residents confirmed this. Residents said staff assisted them with their personal care needs and helped maintain their privacy and dignity. Two residents highlighted concerns about a member of staff that they said was abrupt. The manager was already investigating this. The correct process for dealing with this issue was being followed. There were a number of concerns identified with regards to privacy and dignity that indicates a need for further training with the staff group. Examples of these are: • • • A resident’s bedroom toilet was being used as a storage facility. Two residents were unhappy with the time they were being assisted to go to bed. They said it was too early. Some residents said staff are not as responsive to the buzzers as they could be. DS0000045220.V316342.R01.S.doc Version 5.2 Page 13 Claremont Nursing Home • • • Meals were often lukewarm or even cold. Insufficient supplies of pads used to assist continence. Whilst a resident was being moved inappropriately, a carer told another carer to lift that individual, “just like a baby.” Claremont Nursing Home DS0000045220.V316342.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents expressed that they were happy with what was on offer with regards to activities. The standard of meals provided do not meet everyone’s expectations. EVIDENCE: The home employs an activity coordinator. This person develops a care plan for each resident and keeps regular updates as to what they have been involved in. This person was on holiday during the inspection and there was nothing planned for that week. There is an activities list displayed at the entrance of the home to inform all as to what was planned for the following week. Residents and relatives spoken to said there are planned outings for residents to go on and there are also entertainers brought in. They said that those residents that are able to go out in the good weather are assisted when possible. There are two lounges with televisions. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 15 There was concern expressed about the absence of activity on a day-to-day basis. During the inspection the inspector observed no activities being provided. Staff were observed to be extremely busy and did not seem to have time to interact with residents on a one to one basis or in groups. This was confirmed by speaking to staff, residents and relatives. Three residents spoken to said that they like to stay in their room rather than use the facilities. They said they are encouraged to get involved with the other residents but they choose not to. There are significant numbers of residents living in the care home with dementia care needs. It was difficult to find evidence that showed relevant activities are provided to this group. All those spoken to said they were happy with the arrangements made for visiting, as these were very open and flexible. The residents are provided with regular meals and there is a menu available for residents to view. Residents are offered a choice of meals, which they are asked to choose. Alternatives are offered if they do not like what is on offer. Not all residents are happy with the quality of the meals that are provided by the home. Three residents who take their meals in their rooms said that their lunchtime meals were often cold or lukewarm. Staff said that mealtimes are one of the busiest periods and that they serve meals to those in their rooms last. Staff working in the home are also provided with hot meals at the same time as residents and this can pose a delay on meals being provided at the correct temperature. Staff were observed to be very busy at the main mealtime. They were observed to be very attentive and helpful to those residents that needed assistance. They sat beside the residents and chatted during this process. Regular drinks were offered to residents. Claremont Nursing Home DS0000045220.V316342.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have a good understanding of the complaints procedure and are assured their complaints will be dealt with properly. The system for recording complaints needs reviewed. The care staff have a good understanding of what adult abuse is and how to deal with it appropriately. Not all adult protection issues are referred to the appropriate agency. EVIDENCE: The home does have a complaints procedure within the documentation given to residents and their representatives. It also displays the procedure in different areas of the home. Residents said they do know what to do and who to contact if they needed to make a complaint. They also said they are confident that the home would investigate their complaints properly. The complaints recorded in the home were inspected. There were a lot of complaints made about different issues. The way in which these complaints were recorded did not enable the inspector to identify whether they had been responded to correctly, or whether they had all been completed within the correct timescale. A number of complaints contained information that should Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 17 have been referred to the local adult protection unit for advice but no evidence was seen to show this happened. Staff spoken to showed good awareness of adult protection issues and how to deal with situations relevant to this area. Training is provided by the home and staff said it was beneficial. The manager has recently referred a case to adult protection and this is currently being investigated. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall environment of the home is of a good standard and meets the needs of the residents. EVIDENCE: The location and layout of the home is suitable for the service provided. There are plans in place to build a new extension, which will increase the number of residents living in the home and also the facilities on offer. The organisation has a maintenance team that responds to any environmental problems identified by the staff. Two of the maintenance team were at the home during the inspection attending to jobs. They said that they do have a Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 19 rolling programme of maintenance identified for them and they manage that in consultation with the management team. The overall feedback about the environment and cleanliness of the home from residents and relatives was positive. There are a number of domestic workers employed by the home and they had a good awareness of infection control and COSHH. Three people spoken to said that there were some areas of the home that were Tatty’ and in need of attention. There were a number of areas in the home that were in need of refurbishment. Many of the doors, doorframes and skirting boards were in need of attention as they had become scraped and marked over time. Hallway carpets on the top floor had become very dirty and stained and were not cleaned to an acceptable standard. A double room on the first floor had a floor carpet that was also extremely dirty and stained in many places. Both the manager and the operational manager were informed that these carpets were totally unacceptable in their present condition and that they were in need of urgent attention or replacement. The operations manager said the carpet would be replaced. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident group would benefit from a review of the system of staff working or increased numbers of staff. The recruitment process and training provision needs review and improvement. EVIDENCE: The home has developed a staff rota system and this highlights which staff are working on each shift. Residents, relatives and staff all raised concerns about the levels of staff working in the home. The staff did appear to be very busy in their roles throughout the day and they seemed very task orientated. Resident and relative comments made were, “They work extremely hard but there aren’t enough of them.” “They could have more staff on duty as they are always very busy. They do help me a lot but they have very little time to stop and chat.” “They often take a long time to answer buzzers.” Residents’ relatives made similar comments. Staff spoken to felt quite pressurised with their workloads. Two staff members said, “We aren’t able to give the care we should be giving.” Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 21 This information was passed on to the manager and the operations manager and they gave assurances that this issue would be reviewed. The manager has commenced a rolling programme of enrolling staff onto the NVQ Level 2 training. They are not far off ensuring 50 or more of the carers have been trained to Level 2 or above. The recruitment files for the two most recent carers were inspected. Required information needed before an employee could work at the home was missing. This places residents at risk. Examples of information missing included appropriate references and POVA checks. Residents and relatives said that they thought the staff were good at their jobs and were competent. Training is available mainly in areas of mandatory need such as fire training, moving and handling. Staff spoken to said they don’t receive training in areas relevant to resident need such as; nutrition, continence care, mobility, aggressive behaviour and dementia care. The manager agreed that a training plan to incorporate these areas would be reviewed. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 22 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit if the overall management processes and systems were reviewed and improved. EVIDENCE: The manager has many years experience as a registered nurse and is in the process of attaining NVQ Level 4 training in management. The residents and the relatives are aware who the manager is and feel that they can approach her if they needed to. The evidence in the report shows that there is work to do to ensure the home is meeting the National Minimum Standards for Older Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 23 people. It is positive that both the manager and the operational manager have identified that the home is in need of improvement. The operational manager’s previous two quality audits have assessed the home as providing an adequate service. Staff spoken to said they ‘feel pressurised’. They said that they feel that they are not supported by the organisation and that their jobs are getting very difficult. This situation is not helped by the fact that staff are not being supervised appropriately to do their jobs. The records show that this is an area that has fallen well behind. The carers did say that they do have meetings but they don’t feel as if they can say how they feel at them. The home looks after some residents’ monies and these were found to be correct when randomly checked. The manager has a good system in place to ensure all the necessary checks of the equipment used in the home are appropriately checked. The records were all correct and up to date. Some health and safety issues were identified that needed addressed. These included: • • • • • • Poor manual handling techniques used by carers. Agency nurse working in the home had no up to date training in manual handling. Insufficient supplies of rubber gloves available to staff to help prevent spread of infection. No environmental risk assessment of the property has been carried out. Water temperature outlets dispense water above the recommended 43 degrees. Staff are concerned that they have had to work in the home with only one working hoist. Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 24 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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 1 x 2 Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4,5 Requirement The registered person must ensure all the required information is contained in the Service User Guide. The registered person must ensure the care files and risk assessments show evidence that the resident or their representatives have been involved with their development. The registered person must ensure that any risks identified at admission are properly managed so that the resident is safe. The registered person must ensure consent to look after and administer medication is obtained from the resident or their representative. All medications administered by nursing staff must be administered correctly. This refers to missing signatures on MAR charts. The registered person must ensure staff promote and maintain the privacy and dignity DS0000045220.V316342.R01.S.doc Timescale for action 30/04/07 2 OP7 15 30/04/07 3 OP8 12 28/02/07 4 OP9 12 30/04/07 5 OP10 12 28/02/07 Claremont Nursing Home Version 5.2 Page 26 6 OP12 16 7 OP15 16 8 OP16 22 9 OP17 12 10 11 OP19 OP27 23 17 12 OP28 18 13 OP29 19 14 OP30 12 15 16 OP31 OP36 9,10 18 of residents at all times. The registered person should ensure activities provided on a daily basis are appropriate to the needs of those residents with dementia. The registered person must ensure all residents receive meals to the standard they expect. The registered person must ensure complaints a recorded appropriately and comply with the required timescales. The registered person must ensure any adult protection issue identified within the home is referred to the appropriate agency. The registered person must ensure that all areas of the home are clean and well maintained. The registered person must ensure that suitable numbers of qualified staff are on duty to be able to meet the care needs of the residents. 50 of care staff must be trained to NVQ level 2 or above. The previous timescale of 30/06/06 has not been met. The registered person must ensure all the required information is obtained for an employee before they can commence work. The registered person must ensure that staff receive a training programme that provides them with the skills and knowledge relevant to resident care needs. The registered manager must obtain at least Level 4 NVQ training in management. The registered person must ensure all care staff receive DS0000045220.V316342.R01.S.doc 30/04/07 31/03/07 28/02/07 27/02/07 31/05/07 31/03/07 30/04/07 28/02/07 30/04/07 31/05/07 30/04/07 Claremont Nursing Home Version 5.2 Page 27 17 OP38 12 appropriate supervision. The registered person must ensure the health and safety of residents is promoted at all times. This refers to the concerns raised in this standard. 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. Refer to Standard Good Practice Recommendations Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Claremont Nursing Home DS0000045220.V316342.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!