Inspection on 27/06/06 for Clarence House

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Clarence House 40 Sea View Road Mundesley Norwich NR11 8DJ Lead Inspector Mrs Geraldine Allen Unannounced Inspection 27th June 2006 09:30 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 DS0000066780.V303515.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 DS0000066780.V303515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarence House Address 40 Sea View Road Mundesley Norwich NR11 8DJ 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) 01263 721490 dhoward@inncare.com Integrated Nursing Homes Limited Mrs Denice Jayne Howard Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4 August 2005 Brief Description of the Service: Clarence House is a care home providing personal, nursing care and accommodation for up to 41 older people. Integrated Nursing Homes Limited has owned the home since 25 January 2006. The home is located in the seaside village of Mundesley, close to shops, pubs, the post office and other local amenities. The home has 35 single bedrooms and 2 shared bedrooms. All except 1 single bedroom have en-suite facilities. The majority of communal space is located on the ground floor, however there is a communal lounge located on the 1st floor. There is a passenger lift to all floors. There is car parking to the side and front of the building and gardens are located at the rear of the building. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 27 June 2006. Not all of the National Minimum Standards were inspected on this occasion and, where a standard has been inspected, the complete range of sub elements, as set out in the National Minimum Standards, may not have been assessed. Prior to the inspection the manager, Mrs Howard, competed and returned a pre-inspection questionnaire. Comment cards were also received from 4 residents and 1 relative. On the day of inspection, 2 residents were spoken to in private and lunch was eaten with 3 residents in the dining room. Four staff were spoken to in private and 2 relatives were spoken to. Records were also seen and a tour of the premises made. The home provides good care in an environment that is being refurbished and upgraded to good effect. Since Integrated Nursing Homes Ltd have assumed ownership of this home, changes have been made to the care provided. As a result, the home provides nursing care in addition to residential care and qualified nurses are employed 24 hours per day. What the service does well: What has improved since the last inspection? As stated above, there have been significant improvements to the environment and the company has a plan through to June 2007 that will ensure all areas of the home are refurbished and upgraded. Staff are being given well structured training that will be relevant to the needs of the people living at the home. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 6 The employment of catering and domestic staff has been increased so that care staff no longer need to be taken from their care duties to deal with catering and domestic issues. 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 House DS0000066780.V303515.R01.S.doc Version 5.2 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 House DS0000066780.V303515.R01.S.doc Version 5.2 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, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service User Guide that provides information to potential residents that allows them to make an informed decision to live at the home. All residents receive a contract that provides information about the terms of their residence at the home. This home does not provide intermediate care. EVIDENCE: Residents confirmed they had received information about the home before making a decision to move there. All of residents who completed comment cards or were spoken with felt the information had been sufficient to help them decide to live at the home. Residents also confirmed they have received a contract that sets out all the terms and conditions of their residence. The residents care plans showed that assessments had been carried out before they moved to the home to ensure the home was able to meet their needs. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good care plan formats in place but they need to be dated and signed where necessary. Care plans for residential clients must reflect the assessed needs of the resident. Residents have all their healthcare needs met appropriately. Residents are treated with dignity and their privacy is respected. EVIDENCE: The home has good care plan formats in place for residential clients but these are not necessarily being completed, dated or signed appropriately. The care plans for the nursing clients contained assessment and information relevant to their needs and were dated and signed. Residents receive timely healthcare as necessary and the home accesses all relevant healthcare professionals. The home operates good practice in respect of medicines although care needs to be Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 10 taken that entries are not obliterated when errors on the record sheets are made. Residents feel they are treated well and with respect. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in the way they prefer with their needs and preferences being respected. Visitors to the home are made welcome and can visit when they wish. Residents are enabled to make choices around their daily living and staff respect choices wherever possible. Residents enjoy a diet that is nutritious and well presented. EVIDENCE: Residents and visitors were spoken to and they confirmed that visitors are always made welcome at the home at any time. Residents make choices around how they spend their day and with whom. They also described how they could choose what time they get up in the morning and go to bed at night. Most residents spoke very positively about the food they receive. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 12 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. The home has a complaints procedure that is well known to residents and visitors. There was evidence that the home treats all concerns and complaints seriously and in accordance with its procedures. Residents are protected from abuse by the homes practice and well trained staff. EVIDENCE: The home has a complaints procedure that is displayed in the home and well known by residents and visitors. Records are kept in the entrance hall about any concerns or complaints received and how they have been resolved. The home also keeps all letters and cards expressing appreciation. Staff receive training that ensures they understand about adult abuse issues and how they should deal with any concerns they may have. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 13 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, 20, 22, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The owners of this home are working hard to upgrade and refurbish the home to a good standard. Where work has been completed, it can be seen that standards are good and all required equipment is being provided. The home was clean and tidy on the day of inspection and no unpleasant odours were detected. EVIDENCE: Significant work has already commenced at this home to refurbish and upgrade the environment and its facilities. Work already completed is of a good standard and the refurbishment plan provided by Mrs Howard shows work continuing up to June 2007 in a planned and structured way. On the day of inspection, the home was clean and tidy with no unpleasant odours detected. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home follows good practice when recruiting staff at the home. Staff receive training that helps them to provide appropriate care to the people living at the home. Staff are employed in sufficient numbers to meet the needs of the residents and ancillary staff are employed so that care staff do not need to undertake domestic and catering duties other than in emergencies. EVIDENCE: Staff rotas show that there are sufficient staff employed during the day and night to meet the needs of the people living at this home. Staff are recruited, using good practices such as obtaining references and checks on their integrity. Staff also receive good training to help them meet the needs of the residents effectively. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 15 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, 32, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and experienced person who is well qualified manages the home. Staff understand the ethos of the home and support the residents effectively in accordance with policies and procedures. The home has a comprehensive quality assurance process that has only recently been introduced. Its effectiveness will be assessed once it has been used to produce an annual improvement plan. The home needs to make some improvements to the way they look after resident’s personal allowances so that practice is robust. Residents, staff and visitors to the home are protected by the health and safety practices. EVIDENCE: Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 16 Mrs Howard was appointed manager at the time the home was acquired by Integrated Nursing Homes Ltd. She has supported residents and staff during the transitional period and has ensured that any issues have been dealt with appropriately and in a timely way. The home has recently introduced a very comprehensive quality assurance process that is yet to be fully implemented. It is expected that this will be an effective tool in aiding Mrs Howard to identify any issues and to develop improvement plans as needed. The home needs to ensure that practice is improved to ensure residents personal allowances are handled and recorded securely. The home is well maintained and health and safety matters are dealt with promptly. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 17 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 X 3 3 Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 18 No Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13(2) Requirement The registered persons must ensure that erroneous entries in medication records are not obliterated. Timescale for action 04/07/06 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 4 Refer to Standard OP7 OP7 OP16 OP35 Good Practice Recommendations It is recommended that care plan assessments and reviews are dated and signed in all instances. It is recommended that the care plans for the residential clients are reviewed to ensure they accurately reflect the needs of the individual and how they will be met. It is recommended that information about complaints and concerns is anonymous to respect the confidentiality of the person/s raising their concerns. It is recommended that all financial transactions carried out in behalf of the resident is recorded with two persons signing the records. Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clarence House DS0000066780.V303515.R01.S.doc Version 5.2 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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