Inspection on 08/05/06 for Clarence Care Home

This inspection was carried out on 8th May 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

Clarence Care Home 27/04/07

Clarence Care Home 21/11/05

Clarence Care Home 25/04/05

Clarence Care Home 14/12/04

Clarence Care Home 06/07/04

Clarence Care Home 06/01/04

Similar services:

Cheaney Court Care Home

Chater Lodge

Conifer Lodge

Egerton Lodge Care Home

Edenhurst Care Home

Ernehale Lodge Care Home

Ecton Brook House

Cherry Trees @ Hazel Hill

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

CARE HOMES FOR OLDER PEOPLE Clarence Care Home Huthwaite Road Sutton In Ashfield Nottinghamshire NG17 2GS Lead Inspector Jayne Hilton Key Unannounced Inspection 8th May 2006 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 Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 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. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clarence Care Home Address Huthwaite Road Sutton In Ashfield Nottinghamshire NG17 2GS 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) 01623 558422 01623 558113 Mimosa Healthcare Group Limited Patience Nyoni Care Home 47 Category(ies) of Dementia - over 65 years of age (47) registration, with number of places Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager undertakes training on Adult Protection Issues and the mental health needs of older people within the next twelve months Service users shall be within category DE(E) only (47) Date of last inspection 21st November 2005 Brief Description of the Service: Clarence Care Home is a purpose built two-storey home situated outside the centre of Sutton in Ashfield. It provides residential care only for up to 47 service users with Dementia All bedrooms are single with en suite facilities and the home has four lounges and dining rooms available. There is an enclosed garden to the rear accessed by patio doors from the units on the ground floor and plenty of car parking spaces to the side of the building. Fees range between £319-£487. Information obtained from the manager on 8/5/06 Service users are expected to pay extra for Hairdressing, Chiropody and Newspapers Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on 8th May 2006 between 10am and 3.15pm. The purpose of the visit was to assess the key standards and the progress of requirements set the previous visit. Two service users were interviewed and many others were spoken with throughout the inspection. Six staff members were spoken with at this visit and one relative. A tour of the premises was undertaken at this visit. As part of the inspection methodology, a sample of staff personal files and four care plans and various records were examined including, the staffing rota, complaints records, a sample of accident records, service users financial records, servicing records, fire safety records etc. The manager was not available for the majority of the inspection due to attending a funeral. Equality and diversity is generally well promoted within the home, although there are no service users with specific cultural or diversity needs, a multicultural staff team supports them. What the service does well: What has improved since the last inspection? Recruitment practices are now satisfactory Care plans are now stored securely. The electrical circuit safety check has been carried out. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 6 Service users are now able to make an informed choice about what they eat. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have the information they need about the home and have a written contract and their needs are generally fully assessed. There has been however a breach regarding one service users admission and an immediate requirement issued in respect of this. The home does not provide intermediate care. EVIDENCE: Service users spoken with were able to produce a copy of the service users guide. It is recommended that service users and/or relatives sign within the care plan that they have been issued with a copy of the service user guide. Four care plans were examined and contained detailed assessments, which meet the standard. One service user was admitted in February whose needs were outside the category of the registration of the home. An immediate requirement was made in relation to this prior to the inspection that service users must not be admitted to the home that do not met the legislative requirements of the registration category [Registration Regulations] Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10.11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are generally set out in the individual plan of care. Medication management is satisfactory. 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. EVIDENCE: From examination of four service users care plans they were found to be well written and appeared to meet the needs of service users, these had been reviewed on the whole monthly. Daily progress notes were on the whole well written. Only two pages of daily notes are kept in the care plan folder and then archived. There is a danger that some information may be overlooked, particularly in relation to blood tests and results follow –ups. As healthcare visits are currently recorded on one sheet, again this is difficult to audit trail and particularly when the sheet is archived. It is recommended that healthcare record sheets be separated into appropriate topics. I.e. GP, Chiropody, Annual Healthcare checks/medication reviews etc. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 10 Care plans were in place for other service users who presented challenging behaviour but there is now a system for monitoring and evaluating behaviour. This area could still be further developed. The use of tools such ABC [Antecedent, Behaviour and consequences] would assist in assessing if patterns or triggers of behaviour were evident. Service users spoken with reported that her health care needs were met and prompt referrals were made to the GP when needed. Risk assessments and assessments for mobility, nutrition and tissue viability were in place and reviewed and mostly up to date. The care plans contained a sheet for service users/relatives to indicate how much involvement they prefer in the compilation and review of the care plan, however only one small section in one of the four care plans had been completed. This provided minimal evidence of service user/relative involvement and therefore needs to be further developed. Good records are kept regarding personal care. The wishes of service users for the end of their life were noted to be, well documented and appropriate policies and procedures are in place for staff to follow regarding caring for a person who is dying or upon death. The manager was attending a service users funeral at the time of the inspection. There were still some information sheets in the care plan folders that addressed whether service users wished to be resuscitated in the event of needing CPR. This acts as an advanced statement made by the service user, which states they do not wish to be resuscitated. [DNR]. Service users autonomy must be respected however the inspector advised that these advance directives should be obtained with caution and clear guidance for staff and managers as to who has the ultimate responsibility for the DNR decision [usually a doctor] and regarding service users capacity to make such a decision at the time of admission to the home. No guidance was provided in this documents use and the inspector feels that care staff may be misled to believe that they could make a decision of whether or not to undertake CPR, which is not appropriate. The inspector advised that this document be discontinued as routine practice and service users be asked on admission if they have made any advanced directive that they wish to be included within their care plan. Accidents are appropriately recorded and copies kept in individual service users files. Statistics are kept as part of monitoring falls and accidents. Weights are regularly taken and recorded and note if the service user is not consenting to this procedure. Not all service users have door keys or keys top the lockable facilities in their rooms and there was no documentation for this in care plans. The social needs of service users are basically assessed within the format of the assessment documentation with personal history and lifestyle being generally documented wherever possible. Further development of social, Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 11 leisure and recreational needs of individual service users would improve their quality of life. [See standard 12-15] Service users spoken with confirmed that staff treated them with respect and maintained their privacy and dignity. A service user told the inspector that she gets lots of mail that is always given to her unopened and can use the pay phone in reception or the telephone in the office. Medication management was briefly assessed. The inspector did not observe any administration of medication at the inspection. The trolley when not in use is stored securely in the clinic room. Records examined were found to be neat, photos are used and a sample of signatures was in place. Medication policies and actions to be taken in the event of a drug error are clearly posted on then clinic room wall. The Controlled drugs register was checked and a sample cross reference, evidenced balances were correct. Storage temperatures are kept and medication is recorded as received and disposed of. Staff receive training. There was a recent error made by a member of staff that was reported to CSCI as required. Appropriate action has been taken for prevention of re-occurrence. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Service users maintain contact with family/friends and the community and generally exercise choice and control over their lives, Service users enjoy their meals. The activities provision appears to meet most service users needs, but closer assessment of individual needs and preferences should be explored [and include the right to have their room locked] and written into a plan of care to ensure all service users needs are fully met. EVIDENCE: Visitors are welcomed at any reasonable time and a policy for visiting was clearly in place. The home has employed another activities co-ordinator, which the manager reports that will increase opportunities for service users to go out more into the community, however one of the co-ordinators was on sick leave on the day of the inspection. This has meant a reduction in the activities hours some weeks but full cover is being attempted wherever possible. The Alzheimer’s society is involved with the home. There were conflicting contributions from service users, staff and relatives in relation to activities provision. Some reported that the activities programme suited their needs, others said not. A relative expressed concern that she visited regularly and that stimulation for service users was lacking. Observations on the day of the inspection were that staff were not visible the majority of the time and that Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 13 their time was spent on personal care and routine tasks. Two staff were observed sitting with service users in separate areas of the home on subsequent visits to the units on the day of the inspection. Staff felt that there were activities of some kind provided daily and dominoes was a favourite activity. Some service users were observed to be un-stimulated, and others were watching TV. A visitor commented that when the weather was good the previous week service users were not encouraged to use the garden and that the access doors to the garden were locked. A service user, whose room overlooks the garden, informed the inspector that she likes to watch staff and service users walking in the garden on dry days. Staff stated that service users were using the garden more now the weather is warmer. A trip to a local farm park has been arranged, but a relative reported that the information was misleading as places on the minibus was limiting and that relatives would not be able to travel with her relative who resides at the home. The manager stated that the relative would be offered transport and that staff will be allocated on the day to escort those service users going depending on circumstances on the day. A relative reported that her relative had only been on one trip in three years of residence in the home. There were no written risk assessments in place for trips and outings, although the manager said these are undertaken mentally and verbally with the activities co-ordinator. The manger, staff and service users reported that shopping trips and local walks are arranged and that trips further a field are arranged periodically. The set activities programme is arranged on a monthly cycle and included, Games and moving club, reading the newspaper, home club, art club, photography, books, discussion groups. Entertainers visit periodically to sing or play music for the residents. A visitor thought that there had been no visiting entertainers since Christmas, but service users reported there had been entertainment of this nature since Christmas. Staff reported that they access priests and church personnel as requested and that all religious festivals are celebrated and that there are no service users currently at Clarence with specific cultural needs. Service users and staff spoken with confirmed that service users could go to bed and get up when they wanted and one service user told the inspector that she was able to make decisions in her life. One service user confirmed that she had lockable facilities [but no key] in her room and a key to her bedroom door. Another service user told the inspector that she would like a bedroom door key but had been told there was not one available. The resident was concerned as she had seen other service users wander into her room and had to hide her belongings. The manager reported that the service user would not be able to hold a key. However there was no reference to this in the assessment documentation or risk assessment carried out to evidence this. The service users wishes and rights to have her door locked when she is not there should be therefore facilitated by staff and the appropriate documentation be in place for all service users where applicable. Several service users reported that the food was most enjoyable, however one service user stated that the toast and bacon was not very hot when served. There was evidence of records kept for meal option choices and service users Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 14 spoken with confirmed that they were given a choice of meals. Lunchtime was not observed particularly. A visitor reported that service users were left unsupervised at lunchtimes whilst staff went on to serve meals to another unit and that she had witnessed a service user struggling to eat soup with a fork and that some service users require prompting and supervision to eat. The inspector witnessed a staff member supporting as service user to eat on the day of the inspection and the staff member and manager reported that they are told to be in attendance in the dining room at all times. The manager agreed to address the relative’s observations and ensure that service users were supervised at all times during their meal times. The food seen appeared appetising and nutritious. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their complaints are listened to and said they felt safe. EVIDENCE: A complaints policy is displayed in the home and a response is promised within 5 days. A recommendation is made once again to reflect in the outcome documentation whether the complaint is upheld, not upheld or resolved. It is also recommended that follow ups are made regarding complaints to ensure the service users/relatives continue to be happy that the complaint is resolved and that practice is improved etc. There were two complaints recorded by the home since the last inspection and one which had been made through CSCI anonymously. Complaint issued included staffing issues and attitude; laundry issues and in relation to personal care needs of service users not being met satisfactorily. Service user and relatives spoken with confirmed that they knew how to make a complaint and staff were confident about forwarding service users complaints and that these would be actioned. The provider has dealt with any complaints raised appropriately Most staff spoken with were aware of the whistle-blowing policy and that they would report on any poor practice. Training in abuse awareness has not been provided for all staff. The manager needs to attend training as part of the condition of registration also. One staff member reported that a recent course Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 16 in Dementia covered abuse and dealing with challenging behaviour and that challenging behaviour is dealt with by more experienced members of staff. There has been one incident reported under the Safeguarding Adults protocols in the previous twelve months, which no further action was recommended. Service users finance records were examined and found to be satisfactory. It is recommended that service user/relative signatures be gained on receipts for cash and belongings handed over for safekeeping. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 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): 19-26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an accessible, safe and well maintained environment, which is furnished in a homely way. The home is clean, pleasant and hygienic and provides a safe environment for service users to live. EVIDENCE: A tour of the home was made. The homely environment appeared comfortable and furniture and soft furnishings were in good order and the layout of the home is spacious and service users were observed moving freely within their designated units. The garden area is enclosed. The patio area was level and accessible. Service users bedrooms were noted to be comfortable, personalised and free from hazards and window restrictors were in place throughout. En-suite facilities are provided. Keypads are in place for security. Toilet and bathrooms are adequate and suitable for people with disabilities. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 18 Hoists and appropriate equipment are provided for transfer of service users with poor mobility Call alarms are sited throughout the home. Lighting is of a domestic style and radiators were noted to be of the low surface type. The walkways were being decorated on the day of the inspection. There was some small plaster damage noted to the ground floor toilet near reception. There was overall no mal odour present in the home on the day of the inspection and all areas examined were clean and pleasant throughout. A linen trolley was stored in a bathroom, which could pose a risk of cross infection. Gloves and paper towels were observed supplied throughout. A member of staff commented that they have to work within tight budgets for cleaning products. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet minimum staffing requirements. Recruitment practices were satisfactory. Any training deficiencies are now being addressed to ensure staff are competent to do their jobs. EVIDENCE: The staffing rota was examined for 36 service users in residence 5 care staff are rotered for daytime cover and 3 staff for nights. The manager works supernumery and catering and housekeeping staff appear sufficient. Additional activities provision is also provided. Care staff were observed to be deployed to lounge and dining areas on the day of the inspection, senior staff were observed overseeing and ensuring reports and medication practices were in hand etc. The rota demonstrated that a member of care staff without a food hygiene certificate had been rotered for catering duties on a recent weekend shift. As this type of issue has been raised with the home previously an immediate requirement was made for this not to happen again. All care staff, as food handlers should have food hygiene training and this has been delayed, however that staffs that do not hold a certificate in food hygiene are booked to undertake training in July 06. Updates in training are also booked for Coshh, Health and Safety and infection control and first aid. Most staff has undertaken fire safety, manual handling and Dementia training. Senior staff should hold up to date certification for all mandatory training requirements. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 20 Staff and service users would benefit from staff undertaking training in abuse awareness, food and nutrition, equality and diversity. Recruitment practices were found to be satisfactory at this visit. Four staff personnel files were examined. Three staff hold NVQ3 and five NVQ2 Two staff are currently working towards NVQ2. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are generally safeguarded by the homes, management, accounting and financial procedures in the home, but further development is needed. Quality monitoring systems are currently being expanded upon. Staff are appropriately supervised but again further development of this would be beneficial to all. Record keeping is satisfactory and care plans were stored securely. The health and safety and welfare of service users and staff is generally promoted and protected. EVIDENCE: The manager has been assessed as suitable for registration recently. The manager is a trained nurse. Staff and service users reported confidence in the manager. Conditions of the Registration have been set and must be actioned at once. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 22 Quality monitoring systems are in place, including Regulation 26 visits by the Responsible individual, Audits etc. Service user and relative surveys are prepared and are to be sent out to obtain views about the service. A sample of service users financial records were examined and in the main was in order. Valuables kept on behalf of service users in the safe receipted for, it is recommended that signatures be obtained on the receipt. The system for receipting needs to be improved so that appropriate receipts are attached to the correct record sheet. The administrator and manager confirmed that the accounts are audited periodically and the inspector recommends that this be evidenced on the records. Some staff confirmed that formal supervision takes place, however on examination of staff personal files these are not carried out at least 6 times a year and one staff member had not yet had any supervision. The format currently in place has been revised but needs to be formalised. Senior staff are expected to undertake supervisions and all staff would benefit from any training in this topic. Care plans are now kept secure. A visitor’s book is in use. Accident records were examined and found to be in order and cross referenced to care plans. An appropriate accident book was in use. An induction booklet was examined and health and safety topics were clearly covered. Servicing contracts for equipment and health and safety checks were otherwise in order and evidence was seen of the five yearly electrical safety check and fire risk assessment. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 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 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Service users must only be admitted that meet the criteria of the Service users must not be admitted to the home, who’s needs are assessed to be outside of the category that the home is registered for. Issued 24/04/06 prior to inspection Staff must not undertake catering duties unless they hold an appropriate food hygiene certificate. Immediate. Timescale for action 08/05/06 2 OP18 18 08/05/06 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 2 3 Refer to Standard OP1 OP7 OP8 Good Practice Recommendations Provide evidence within the care plan that service users have been issued with a service user guide Further develop ways to involve service users and relatives in the care plan process Separate out the records of healthcare checks and provide clearer audit trails for blood tests and results follow-ups. DS0000008746.V293490.R01.S.doc Version 5.1 Page 25 Clarence Care Home 4 5 6. 7. 8 9 OP12 OP14 OP16 OP26 OP27 OP18 10 11. OP33 OP35 12. OP30 13. OP36 Review the use of the Do Not Resuscitate sheets as identified within the report. Further develop the social/leisure needs of service users to ensure all individual needs are being fully addressed and met Ensure service users wishes are respected in relation to security of their room and that their right to have a key is upheld unless documentation states otherwise. Further develop the complaints format to include whether the complaint is upheld or not and follow ups are documented. Towels\and linen stored in bathrooms/toilets present a risk of cross infection. The open linen trolley should not be placed in any of these rooms. Review the staffing levels in relation to the provision of more supervision and stimulation and general quality of life for service users. Staff should have training in the following: Equality and diversity Abuse awareness Food and nutrition Senior staff should hold up to date certificates in mandatory topics. Ensure service user surveys are sent out promptly and feedback is reported on the outcomes. 1. Improve the financial procedures as described in the report. 2. Provide signatures on receipts for valuables kept on service users behalf 3. Further develop the policy for shopping on behalf of service users regarding staff not benefiting from service users purchases. 4. Ensure there is evidence that the financial processes are audited. Staff should have training in the following: Equality and diversity Abuse awareness Food and nutrition Senior staff should hold up to date certificates in mandatory topics. Formalise the supervision process and discussion and ensure staff are offered up to six sessions a year. The manager and senior staff would benefit from training in supervisory skills. Clarence Care Home DS0000008746.V293490.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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