Inspection on 15/10/08 for Clarence House

This inspection was carried out on 15th October 2008.

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 House 08/03/10

Clarence House 10/11/09

Clarence House 14/02/08

Clarence House 16/04/07

Clarence House 29/08/06

Clarence House 10/04/06

Clarence House 03/11/05

Clarence House 28/04/05

Clarence House 11/01/05

Clarence House 20/10/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Clarence House 42 Warwick New Road Leamington Spa CV32 6AA Lead Inspector Patricia Flanaghan Key Unannounced Inspection 09:00 15th October 2008 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 House DS0000040534.V372773.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. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarence House Address 42 Warwick New Road Leamington Spa CV32 6AA 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) 01926 832826 01926 882677 Dr Jeyaratha Sivasoruban Mr Kanagasabai Sivasoruban Manager post vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (16) of places Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. RECOMMENDED CONDITIONS OF REGISTRATION That the Registered Manager enrols for appropriate training to obtain a qualification in the management of a care home at NVQ Level 4 and that he obtains this qualification by 1 April 2005. That until the Registered Manager has obtained a qualification as a care home manager at NVQ Level 4 the Registered Providers will employ a person as Deputy Manager who is suitably experienced/qualified in the supervision of staff who are providing personal care to elderly people. That the Registered Providers will notify the Care Standards Commission of the name and qualifications of the Deputy Manager. That on any change of Deputy Manager the Registered Providers will notify the Care Standards Commission of the name and qualifications of the new Deputy Manager. Date of last inspection 14th February 2008 Brief Description of the Service: Clarence House is a large Victorian property that was converted from a hotel to a care home in 1984. The home has parking to the front and garden at the rear. There is a ramped access to the front door. The home is situated ¾ of a mile from the town centre with all major facilities readily accessible. The home provides care for 21 older people (including 5 people with dementia care needs) with a wide range of needs, e.g. physical disability, sensory loss, general frailty and other conditions often associated with old age. The accommodation is arranged on three floors, there is a shaft-lift and a chair lift to ensure accessibility. On the ground floor there are two communal lounges with a dining room situated between them. Also on the ground floor there are four single bedrooms and one double bedroom. On the first floor and mezzanine floors, there are seven single and one double bedroom. On the top floor there are a further three bedrooms, one of which is a double room with an en suite. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate outcomes The last ‘Key’ inspection took place on 14th February 2008. Following identified areas of concern we visited the service again completing a random inspection in June 2008. During the random inspection in June we evidenced poor medication management, poor record keeping, and a lack of sufficient detail in dealing with complex care needs of the people who use the service. Because of these concerns and previous information provided by other professionals, the Health and Social Care Directorate have not been placing any people at Clarence House. This key inspection showed improvement in a number of key areas. We could see that the owner, manager and staff are making progress to ensure that Clarence House is meeting the needs of those people who live there and are ensuring that legal requirements are met. Three people who were staying at home were ‘case tracked’. This involves establishing an individuals experience of living in the home, meeting or observing them, discussing their care with staff and relatives, looking at their care files and focusing on the outcomes for the person. Tracking peoples care helps us to understand the day-to-day life of people who use the service. Records examined during this inspection, in addition to care records, included, staff recruitment records, training records, social activity records, staff duty rotas, health and safety records and medication records. The owner was present throughout the day and we were able to tour the home, and spend time speaking with people who live there, visitors and staff. What the service does well: The home offers the people comfortable surroundings, which are clean, free of offensive odour and generally safe and well maintained. Relatives and friends were seen coming and going from the home and appeared comfortable and welcomed. One relative commented “My relative is looked after very well. I think the staff are brilliant.” Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 6 There are good written risk assessments that tell the staff where a person is at risk and what actions to take to reduce this risk. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clarence House DS0000040534.V372773.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 Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. A full assessment is carried out before admission that shows what the persons needs are, this ensures that the service can meet these needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Service User Guide and Statement of Purpose are available but both require some changes to ensure that it is up to date. A colour Brochure is also available that gives basic information about the home. The clinical manager told us that the Brochure is given to all those who visit the home and enquire about admission but it is not normal practice to give them a Service User Guide. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 10 There has been one new admission since the last inspection. There are various records available which show that a full assessment of present needs and past medical and social history was carried out. The admission process has improved since the last inspection and now includes a full assessment of needs, ‘Aims and Hopes’ written in the first person, and information from other professionals and those who have been involved with the person prior to admission to the home. The person admitted was unable to tell us their experience of this service, but on observation interacted well with the carers and was smiling and laughing. The manager does not write to the person prior to admission assuring them that their needs can be met and the conditions of admission. It is recommended that this be done. Clarence House DS0000040534.V372773.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. Each persons needs are set out clearly in a care profile ensuring that their social and health care are met. The medicine management was improved. Staff are competent in handling medication and are able to fully support the residents clinical needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: To establish that the needs of those who live at this home are being met we examined four care profiles to ensure that needs are recorded and information is easy to find. We asked some of the people who live there what their experience is and spoke to relatives. Staff also told us what care these four people receive. The hairdresser and activity organiser also spoke with us about their views of the service. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 12 The written information has improved since the last inspection. There is a clear description of what care staff should do to meet each persons needs and the difficulties that can be encountered and how to manage these. There are clear risk assessments that state what the risk is and actions to be taken by the staff to reduce these risks. These risk assessments are re-visited monthly and any changes to the risk or the actions to be taken by staff are recorded. Three staff discussed with us the care needs of the four people we had chosen to examine. They showed us that they knew what was required and understood what they needed to do. One care staff had very poor English skills and was unable to tell us what she did, on observation she showed that she could communicate at a basic level with the people who live there and was able to carryout basic care needs. Relatives spoken with told us that they had noticed an improvement in the service recently and said that they were happier with the care their relatives received. One person who lives at the home told us that they felt sad and unhappy but that this was not due to the care. They said that the care is good and they are able to choose what they do during the day, that staff listen to them and help when needed. Staff were seen interacting with this person, offering reassurance and responding to their needs. Safe moving and handling practices were seen. Two staff assisted a person to move from a wheel chair to another chair using a hoist. They told the person what they were doing and used the equipment properly. Those assisted to move around the home in wheelchairs were done so safely. The care staff spoken to were able to tell us how they ensure that people who have poor mobility are helped so that they do not develop any sores due to prolonged pressure. One person who has no mobility was sitting on a pressure-relieving cushion and had a mattress that helps to reduce pressure. This person had no sores or damage to their skin due to pressure. It was found that for short term problems such as chest infections, swollen legs, infected eyes the manager has not written ‘short-term’ care plans to ensure that the staff are fully aware of the care needed. This was discussed and paper work is available and the clinical manager stated that this would be started. Care for short term problems was being carried out by the staff and they told us that they tell each other what is needed at the beginning of each shift. There is a risk that verbal communication relies on staff memory and understanding and may result in some areas of care being missed. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 13 Care staff have received training in Dementia Care and the interaction of staff with those people who have dementia was improved since the last visit. The pharmacist inspection lasted two hours. Six residents medication was looked at together with their medicine charts and care plans. The drug round was observed and one care assistant was spoken with. The medicine management had improved to a safe level. All nine requirements were met from the last inspection. Audits indicated that the majority of medicines had been administered as prescribed. A system has been put in place to check the prescriptions prior to dispensing and to check the medication that is delivered to the home. This was not always carried out for medicines prescribed outside the 28 day cycle, so these medicines were not checked in as well as they should have been. One error was seen on the medicine chart. A cream was to be applied daily but staff were administering it twice a day. The manager said that the doctor had told her that it was to be applied twice a day, but the prescription he wrote recorded daily. This had not been confirmed with the doctor. Medicine charts were clear when a dose had been changed and staff were able to see the new dose and administer it correctly. Care plans were very good and recorded the clinical condition of the residents together with medical information about the medicines they handled. One care assistant spoken with had a good understanding of the medicines she handled. Medicines were correctly stored and a new lockable medicine refrigerator had been purchased. The manager undertakes regular audits to confirm that staff are administering and recording medicines correctly. The medicine round was observed and the care assistant read the medicine chart before she prepared the medication, took this to the resident and signed the chart directly afterwards. If the resident was not in the lounge she still took the open pot of medicines to the resident instead of using the medicine trolley. Concern was raised that the clinical manager used an invasive procedure to administer a medicine. The administration had not been recorded on the medicine chart; no prescription was seen to confirm the correct dose. The only reference that this procedure had taken place was in the care records. Clarence House DS0000040534.V372773.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 adequate. Some activities and stimulation are in place but they need to be improved upon to further stimulate people living at the home. The catering arrangements at the home meet the needs of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a very relaxed atmosphere throughout the course of the inspection. The interactions between the staff and the people living in the home were very friendly. There were no rigid rules or routines. People were seen to wander freely around the home. During this visit there was a lot of activity going on. An outside entertainer who involved people with armchair exercise and movement made a visit. A number of people were actively involved and others observed. The ‘Story Teller’ also visited. We had a discussion and were told that she visits twice a week for about an hour. During this time she reads stories, spends time with individual people looking at photographs, playing board games and Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 15 doing crafts. She does not record these sessions in the home and there was some information available that staff had completed but this is not continually done. She told us that they care staff are very caring and that they meet all the health care needs of the people who live there. It was noticed during the day that when there was time where the care staff could involve themselves in activities with the people who live there they often did not. The hairdresser was at the home and told us she has always found staff very supportive to residents. The lunchtime meal was served in the dining room. Everyone ate all their meal and the care staff assisted those who needed help. The dining room was relaxed and each person ate at their own pace. Three people spoken to stated that they enjoyed their meal and had enough to eat. Staff were seen asking individuals if they would like any more. During the meal two people had a disagreement and the staff managed this well, calming the situation and ensuring that both people could continue to eat their meal. The Kitchen was clean and both staff were aware of their roles. All paperwork required to be kept was available. Clarence House DS0000040534.V372773.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. People are given information about how to complain and know who to speak to. Systems in place to protect people from the risk of abuse require improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure displayed in the entrance hall gives clear information on how a person could raise any concerns about the service. We had received a concern from a member of the public that the home was operating with insufficient staff. Duty rotas seen indicated that there are always sufficient staff on duty to meet the needs of the people currently living in the home. The owner told us the home had received two complaints, but these were not recorded in a complaints log. We were shown a copy of the investigation into a recent complaint, but evidence was not available to demonstrate that the home had responded appropriately to the complainant. The home should maintain a record of all complaints received, with details of the investigation, the outcome, any action taken and whether the complainant is satisfied or not. There has been a recent incident where an injury to a person living in the home was sustained. This incident was reported to the Vulnerable Adults Team at the local authority and is currently under investigation. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 17 From the limited records available on the day of inspection we saw that the majority of staff had training in the recognition of adult abuse. However, they did not appear to be fully aware of the “Whistle Blowing” policy. The clinical manager told us that some staff had recently raised concerns about the care practices of a member of staff. They felt the owner did not take their concerns seriously about the staff member. We spoke with the owner and reminded him of his responsibilities in relation to adult protection. The home needs to ensure that all staff, including the owner, have training in safeguarding and whistle blowing procedures. Clarence House DS0000040534.V372773.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, 24 and 26 Quality in this outcome area is adequate. People live in a home, which is maintained, homely, clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides accommodation over two floors. There is a dining room and communal lounge on the ground floor. The public areas in the home were decorated to a satisfactory standard. On the day of the inspection, all parts of the home were clean and tidy. There were no unpleasant smells evident. The corridors were free of obstructions, so that people could move freely and safely through the buildings The gardens had been tidied since the last inspection visit, with the old cars and the broken equipment being removed. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 19 Bedrooms viewed looked homely and were furnished to meet the needs of people living in them. Rooms contain some of the people’s own possessions such as furniture, pictures and ornaments. Some of the bed linen and towels were worn and some pillows were thin/lumpy. All linen and pillows must be reviewed and replaced where necessary to ensure people’s comfort. The laundry is situated in the basement. The organisation of the laundry had improved and the room was noted to be tidy and organised at this visit. The owner told us of his plans to refurbish the laundry area by replacing the flooring and fitting new sinks. Staff have access to gloves and aprons, all communal toilets and bathrooms have liquid soap and paper towels. These measures will help reduce the spread of infection to residents. Clarence House DS0000040534.V372773.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. Further staff training is required to ensure staff have the skills and knowledge to meet people’s needs consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection visit there were 16 people living in the home. Staffing levels were appropriate for the numbers and needs of the people living in the home. There were three to four care staff working during the day and two at night. The manager’s hours were supernumerary to the care rota and the home also employs catering and domestic staff. In the information the home provided before the inspection it was confirmed that 100 of care staff have a National Vocational Qualification (NVQ) at level 2 in care. We saw some of the certificates on staff files to confirm this. No new staff have been appointed since our last visit in June 2008. We looked at training records for two members of staff. We saw Dementia Awareness training and Mental Health awareness training had been undertaken in March 2008. The owner has not yet devised an ‘at a glance’ training needs Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 21 form which would tell him what training to plan for to keep staff updated. We asked for details of staff training to be forwarded to us following the inspection. To date, this has not been received. We are not certain that staff have the appropriate skills and training to manage all the needs of the people who live at this service. .A visitor told us that staff were very kind, but it was sometimes difficult to understand what the staff are saying. Clarence House DS0000040534.V372773.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. The home is generally run in the interests of the people using the service and they are consulted about changes, so they are able to influence changes and have some control of their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner of the home said he is managing the home and intends to apply to us to be registered as the manager. He told us he is currently undertaking his Registered Managers Award (RMA). This award is designed to assist managers’ in understanding their role and increases their skills in running this type of service. He is supported by a clinical manager who is a registered nurse. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 23 As at the previous key inspection visit in February 2008, we saw some evidence of a formal quality assurance and monitoring process. We were shown some quality questionnaires that had been returned by residents or their families. However, there was no evidence that any of the information from the surveys has been used to assist in the development of action plans. The opinion of people using the service should be considered during the development of action plans so people know the home is run in their best interest. There was no evidence that the management have meetings that involve the people who live there or their relatives. This type of meeting assists in informing all parties of changes and developments and also information about what could be done to improve the service could be gained. The personal monies of people living in the home are kept securely in separate bags and accurate records of income and expenditure are kept. Audits of the personal monies for two people were found to be correct. We saw from staff files that supervision is being undertaken by the clinical manager. Records available show that areas covered include: observation of care practices, personal care and training. Information sent to us in the AQAA in April 2008 tells us that equipment is serviced or tested as recommended by the manufacturer or other regulatory body. There are organisational systems in place for the routine servicing of equipment and fire, heating and electrical systems. Equipment seen during the inspection was in good order. For example, review of the paperwork and records for the regular maintenance of equipment such as hoists, fire equipment and emergency call equipment shows this to be all in order. From the limited training records available, we saw that the last fire safety training for staff was in August 2007. All staff should receive refresher training to ensure they are supporting and promoting a safe environment for the people living and working in the home. Clarence House DS0000040534.V372773.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 17 X 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 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 3 X 3 Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13(4) Requirement Plans of care for individuals’ needs that are short term, such as chest infection needs further development. This will ensure people’s health care needs are met in a consistent manner. Further training is required to ensure that all staff understand what a medicine is for, why it has been prescribed and their general side effects. This is to ensure that the clinical needs of the service user are fully met. 3 OP18 13 Arrangements must be made to ensure that senior staff are aware of the procedure to follow if an allegation or suspicion of abuse is reported to them. This is to protect the people living in the home from potential harm. Staff should receive training on Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 26 Timescale for action 31/12/08 2 OP9 13(2) 31/12/08 31/12/08 Adult Protection, “whistle blowing” and the Management of Challenging Behaviours and Restraint. 4 OP38 13 Arrangements must be made for all staff to have up to date mandatory training in Fire Safety. This is to ensure that people in the home are protected from the risk of harm. 31/12/08 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 OP9 Good Practice Recommendations All medicines prescribed on a when required basis should have a supporting protocol to ensure they are only given when needed and not routinely. The medicine chart must record the current drug regime as prescribed by the clinician. Any discrepancies should be confirmed with the clinician immediately. Staff should transport medicines throughout the home in a safe manner and all medicines should be able to securely held in a locked facility in the event of an emergency 2 OP12 Individual profiles should be further developed and where appropriate used to inform care planning. Appropriate recreation/stimulation should be provided every day to meet the assessed needs of the residents. Residents should be consulted about a programme of activities that takes into account individual and group needs. Details of planned activities should be displayed in the home so that residents are aware of what is planned for the day and can plan their time accordingly. Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 27 3 4 OP16 OP24 The home should maintain a record of complaints received detailing the date, investigation and outcome. An audit of all linen, pillows and mattresses must be undertaken and items replaced that are worn/damaged to ensure residents comfort when in bed. The home should develop a training matrix showing dates of training and training due for all staff to ensure they are kept up-to-date with necessary training to support and protect people who use the service. A suitable system for reviewing and improving the quality of care provided must be implemented to demonstrate that the home is being run in the best interests of those living in the home. 5 OP30 6 OP33 Clarence House DS0000040534.V372773.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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