Inspection on 28/04/05 for Clarence House

This inspection was carried out on 28th April 2005.

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

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

Other inspections for this house

Clarence House 08/03/10

Clarence House 10/11/09

Clarence House 15/10/08

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 11/01/05

Clarence House 20/10/04

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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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clarence House 42 Warwick New Road Leamington Spa Warwickshire CV32 6AA Lead Inspector Patricia Flanaghan Unannounced 28, 29 April & 5 May 2005 -12:30 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 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 E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clarence House Address 42 Warwick New Road Leamington Spa Warwickshire CV32 6AA 01926 832826 01926 882677 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dr Jeyaratha Sivasoruban Mr Kanagasabai Sivasoruban Mr Kanagasabai Sivasoruban PC 21 Category(ies) of DE(E) 5 registration, with number OP 16 of places Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION 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 11 January 2005 Brief Description of the Service: The home provides residential 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. Clarence House is a large detached Victorian property with parking to the front and garden at the rear. There is a ramped access to the front door.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 en suite facilities. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out over three weekdays between the hours of 10:00 a.m. and 4:10 p.m. The inspection took place over a total of 13 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. During the inspection a partial tour of the premises was made, 7 residents, 1 relative and 3 members of staff were spoken to. Discussion took place with the registered manager and the care manager. The assessment information and care plans for 4 of residents were seen. A selection of staff personnel files were examined. What the service does well: What has improved since the last inspection? Since the last inspection some new furniture and furnishings had been obtained in some rooms. New carpets have been fitted in communal areas and stairways. Plans for building improvements had been agreed and work on refurbishing the kitchen commenced on the third day of the inspection. The work had been carefully planned to cause as little disruption as possible to the service users and their care. Staff are making steady progress with the National Vocational Qualification training. Three members of staff have been trained to NVQ Level 2 in Care. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 6 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 E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 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 standard(s) 1, 3 and 4 The residents’ records do not indicate that an assessment of need is undertaken prior to admission or that the prospective resident and/or their representatives have been involved in care planning. This does not give prospective residents the assurance they need that the home can meet their needs. EVIDENCE: A copy of the recently produced Service Users Guide was seen at this inspection. It is noted that the claims and statements within the home’s Statement of Purpose are not being upheld, as evidenced throughout this inspection and report, this includes the promise of properly prepared personal care plans and risk assessments. The care records for four service users were checked at this inspection. The assessment information is incomplete in all records and in two cases an assessment had not been undertaken at all. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen to be out of date within two of the service user plans. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 9 Very few risk assessments have been completed for the four plans and those that have are not dated. There is no evidence that the residents or their representatives have been involved in developing the care plans. All staff have recently updated their training in ‘Dementia Care.’ Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8 and 10 There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet the current residents needs. Residents are treated with respect and dignity when their care needs are being attended to. EVIDENCE: The care planning documentation and files of five residents were examined during the inspection visit. Although there have been some slight improvements in care planning, more work is required to demonstrate within the records that all of the residents’ care and health needs are being met. Care planning information is incomplete or, in one file seen, unavailable. The manager has made some attempt to put together some information, but all of the care records seen at this inspection were missing vital pieces. Many of the records completed were not dated or signed; therefore it was not possible to evidence regular review. There is no written evidence that the residents are being weighed regularly or that they have received the services of opticians, dentists, hearing specialists or other medical professionals. For instance, the continence nurse was observed visiting a resident, however, this visit had not been recorded on the resident’s “Medical Visits” file. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 11 Discussions with the care manager and staff during the course of the inspection indicated that some care needs were being addressed even though there was a lack of clear plans and guidance. This approach is dependent upon staff memory and good verbal communication systems. Daily notes completed by care staff did not always provide comments relevant to each service users needs. For instance, the notes for one resident recorded that “… has been fine today.” However, during the inspection it was observed that this resident had not eaten much lunch and staff advised that breakfast had also been refused. These records were not consistently dated. Some of these entries tended to be repetitive and the manager should monitor these entries to ensure that staff individualise daily records rather than using standardised phrases and statements. Residents said that they were well looked after and that the staff were kind and helpful. A relative visiting the home during the inspection visit also confirmed this. Residents were observed to be addressed courteously and assisted by the staff when necessary. The relative of a resident stated that they can see their relative in private if they wish. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15 Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. The meals in the home are good offering both choice and variety. EVIDENCE: The home employs an activities co-ordinator for 32 hours a week. Attempts have been made to organise ‘in-house’ activities, however, the co-ordinator advised that some activities are poorly attended, but that the staff have tried hard to motivate them. This was confirmed in discussions with several residents. Records of activities undertaken were maintained on residents’ individual files. Recent activities have included trips to Peterborough at Christmas for shopping, local social clubs and theatres. The home has a minibus and residents are taken on drives through scenic routes to local beauty spots. One resident stated that she was happy to remain in her room and not join in with any activities and that care staff respected her decision. The Statement of Purpose for the home states that the leisure interests and hobbies of residents will be accessed and these will be built into the activities of daily living of the individual resident. There was no evidence on any of the five files examined of this review taking place. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 13 A hairdresser visits at least weekly and church services are available monthly. Many residents were noted to have visitors during the course of the inspection. Lunch was shared with the residents in the pleasant dining room. The permanent cook has recently left temporarily, however, the deputy manager was undertaking catering duties with the help of a kitchen assistant. The residents said that they are offered alternatives every day and a menu is on the dining room wall. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and they were observed being assisted by staff who were knowledgeable of their likes and dislikes. Several residents spoke of their satisfaction with the meals and choices offered. The kitchen is undergoing major refurbishment. Appropriate arrangements were in place to ensure that there is as little disruption as possible to the service users and their care. The manager advised that the Environmental Health Office will visit the home to assess the new kitchen when it is completed. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 and 18 The home’s policies and procedures, including recruitment and a lack of Adult Protection training do not adequately demonstrate that residents are fully protected from abuse. EVIDENCE: The complaints procedure is incorporated into the Home’s Statement of Purpose. The procedure seen on the back of residents’ bedroom doors was out of date and referred to the previous owners of the home. No complaints have been received by the home or the Commission for Social Care since the last inspection visit. The home has not updated the adult protection policy in line with the local Adult Protection Procedures. Staff have not received the necessary training on recognition and prevention of abuse. It is therefore difficult to evidence that staff would respond appropriately to any suspicion or allegation of abuse. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20, 23, 24 and 26 The home is generally well decorated and is reasonably furnished. Although many improvements have taken place, the home is let down in some areas of the environment by inadequate cleaning. EVIDENCE: The communal areas, bathrooms and some bedrooms were seen during the inspection. Since the last inspection the lounge has been decorated and new carpets have been fitted in communal areas. The carpet in the lounge and dining area is already showing signs of wear and tear, despite regular cleaning. A number of chairs in the lounge area were grubby and in need of cleaning or replacing. The three piece suite in the main lounge is worn and very low and not considered appropriate to the needs of frail older people or staff assisting them. Staff members were seen to have to bend low to assist residents up from the chairs and sofa. This practice puts staff at risk of injury. It would also be difficult for some residents to get up themselves from this furniture and residents may consider this a form of restraint. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 16 A number of areas in some bedrooms require attention. The dirty chair in a bedroom identified to the care manager required immediate replacing. The wallpaper in a bedroom downstairs is torn and coming off the wall in places. There was a leak in the ceiling of this bedroom and further work is required to ensure the initial problem has been remedied. The chair in this room also requires replacing. The carpets in some of the bedrooms seen are wearing thin. The grounds to the home appeared safe and were accessible to residents. There was no evidence of a formal programme of routine maintenance and renewal of the fabric and decoration of the home. A cleaner is employed for a total of 20 hours over 5 days. There was evidence that this does not appear to be sufficient as the home was dusty and grubby in places. The care manager advised that the home are seeking to recruit a second cleaner to ensure cleaning standards are raised. A sluice has not yet been installed in the home. Appropriate hand washing facilities were not always available in the toilets close to communal areas. An effective and hygienic laundry service for residents clothing and bed linen was in place. Work on a ground floor bathroom has not yet commenced. The registered manager advised that this work would commence later in the year. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The procedures for the recruitment of staff are not robust and appropriate checks are not being carried out and potentially leave residents at risk. Staff training lacks planning and coordination. EVIDENCE: No new staff have been employed by the home since the last inspection visit on 11 January 2005. A previous requirement was made regarding the recruitment procedures in the home., Criminal Records Bureau (CRB) checks were not being applied for appropriately and vital information was missing from personnel files. Files of three staff members examined demonstrated that not all of the necessary pre employment checks had been completed. The file of one staff member was empty apart from a CRB check. The care manager advised that the contents of this staff member’s file could not be found. The other two staff members files did not contain CRB checks. Evidence was available to demonstrate that CRB check forms were in the process of being completed for all staff, but 6 staff members had still to bring in documentation in support of the applications. There are 12 staff employed in the Home who do not have a current CRB check and an immediate requirement was made that applications be completed and sent for all staff within ten working days of the inspection. One of the files examined contained only one ‘to whom it may concern’ reference. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 18 Limited staff training records were available and it was not possible to accurately identify what training staff had attended. The NVQ Assessor for the home advised that three staff members have achieved an NVQ Level 2 in Care. A further staff member is doing an NVQ Level 3 in Care. The care manager was unable to demonstrate that copies of the GSCC, (General Social Care Council), code of conduct had been given out to the staff. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 38 Both the registered manager, who is also the owner, and the care manager are demonstrating good leadership skills, whilst acknowledging the areas in which the home needs to improve. Staff training in health and safety is being better organised, but not all safety checks have been carried out at the required intervals, leaving residents vulnerable. EVIDENCE: The majority of the day to day running and management of the home is the responsibility of the care manager. She has worked at the home for some years, latterly in a senior role. The manager is to commence the Registered Managers’ Award and NVQ4 in care in the near future. Formal supervision of staff has not been undertaken by the care manager. Work is still being undertaken to address staff training needs and as yet there is no evidence that all staff are attending mandatory courses and the refreshers at the recommended frequencies. A training needs analysis had not been undertaken for each member of staff. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 20 Fire Safety training was completed in January 2005. Records indicated that a fire drill had been undertaken during a day shift. A fire drill had not yet been undertaken at night. All staff have recently undertaken Moving and Handling Training, however, no training has been given to staff on correct use of the recently acquired hoist. The service certificate does not identify that it relates to this hoist. Medication training has been provided by the home’s community pharmacist. A discussion was held with the manager on the benefits of staff undertaking a distance-learning course with a local college, on the safe administration of medication. Prevention of abuse, the management of challenging behaviours and restraint training remains outstanding. It is also unclear if all staff have an up to date Food Hygiene certificate. An examination of accident records demonstrated that there is inadequate recording of accidents/incidents by staff. A Regulation 37 notice had not been received by the CSCI in respect of the most recent accident to a resident in the home. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 2 x 2 STAFFING Standard No Score 27 x 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 2 x x x x 1 x 2 Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 22 Yes 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 1 Regulation 5 Requirement The registered manager must review the the Statement of Purpose and Service Users Guide to ensure that all information included is current. An assessment of need must be carried out on all service users, which contains all of the information listed in NMS 3.3. Based on this information a care plan for daily living containing longer-term outcomes must be developed and open to monthly review. The care planning system must be further developed: Care plans must be written for each resident detailing how their care needs are to be met and this must include their health, personal, social care needs and their preferences. Care plans must be reviewed and updated monthly to reflect the residents changing needs. Care plans must be written and reviewed with the involvement of the resident and/or their representative. The daily report must include detail of the activities that the resident had engaged in that day. E53 S40534 Clarence House V225147 280405 Stage 4.doc Timescale for action 31 July 2005 2. 3 14 31 July 2005 3. 7 15 31 July 2005 Clarence House Version 1.30 Page 23 4. 7 13,14,17 Schedule 3 12, 13 5. 8 6. 16 22 7. 18 12 (1) 8. 18 13 9. 10. 19 21 23 23 11. 24 16 12. 24 16 Risk assessments needs to be developed on an individual basis for the service users, both in daily living activities within the home and within the community. More information must be included in the care plans with regard to health and medical needs and interventions, which will allow for methodical monitoring and will provide more evidence that health care needs are identified and professional medical services accessed as necessary. The complaint procedure must contain accurate information relating to the current provider and the CSCI. The home must review the Adult Protection Procedure. It must be in line with the Local Authority procedure and the Department of Health guidance, No Secrets. (Previous timescale of 11/01/05 not met). Staff must receive training on Adult Protection, The Managment of Challenging Behaviousrs and Restraint. (Previous timescale of 11/01/05 not met). Grubby or worn chairs in communal areas must be cleaned or replaced. A third bathroom must be provided for residents on the ground floor, plans must be submitted to the CSCI prior to commencing work. (Previous timescale of 31/07/05 is extended). Redecorate the ground floor bedroom following a water leak. Replace the chair in this bedroom. Replace the chair in the bedroom identifed to the registered manager. 31 July 2005 31 July 2005 31 July 2005 31 July 2005 31 July 2005 31 August 2005 31 October 2005 31 July 2005 28 April 2005 Page 24 Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 13. 26 16 14. 26 13, 16 15. 29 19 16. 30 18 17. 30 12 18. 33 24 Install a suitable sluice which meets the needs of the residents. (Previous timescale of 31/10/05 is carried forward.) All areas of the home must be hygienically clean and hygienic. Hand washing facilities must be available. The registered manager must ensure that all information and pre employment checks are completed for new staff prior to commencing duty. This includes a CRB and POVA check and two written references, one of which must be from the previous manager. Gaps in employment history should be fully explored and records kept. A review of current staff files must be undertaken and ensure that all information as specified in Schedule 2 of the Care Homes Regulations 2001 is maintained on file. The outstanding CRB checks for the 12 members of staff must be obtained. (Previous timescale of 31/11/04 and 11/01/05 and not met.) The registered manager must provide a written staff training and development programme for 2005/6. A completed staff training matrix must be forwarded to the Commission. This should include induction, NVQ and mandatory training. (Previous timescale of 11/01/05 not met.) The registered manager must complete an audit of staff training attended. (Previous timescale of 11/01/05 part met.) The registered person must establish and maintain a system for reviewing and improving the quality of care provided at Clarence House and shall supply 31 October 2005 30 June 2005 20 May 2005 31 July 2005 31 July 2005 31 August 2005 Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 25 19. 36 18 20. 38 13, 17, Schedule 3 13, 23 21. 38 22. 38 23 23. 38 37 24. 38 13(4) the CSCI a report in respect of any review. (This requirement was not assessed on this occasion.) A formal staff supervision programme is implemented on a six times a year basis for each staff member and records of the supervision to be kept. (Previous timescale of 11/01/05 not met.) The manager must review the accident/incident reporting procedures and ensure that accurate records are maintained. The resident hoist must be serviced in accordance with Lifting Operations and Lifting Equipment regulations. The registered manager must ensure a fire drill is undertaken for night staff. (Previous timescale of 11/01/05 not met.) The home must inform the CSCI of any accidents or incidents that affects the health or welfare of residents as per Regulation 37 notification. The registered manager must risk access the three piece suite of furniture in the main lounge ensuring that the design is appropriate to the needs of the residents and to staff assisting them. 31 August 2005 31 July 2005 31 July 2005 31 August 2005 05 May 2005 30 June 2005 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 19 Good Practice Recommendations The registered manager should produce a programme of routine mainteance and evidence of renewal of the fabric and decoration of the premises. The programme should include costing and implementation. (Previous timescale of E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 26 Clarence House 2. 3. 29 11/01/05 not met.) Copies of the General Social Care Council Code of Conduct should be obtained and given to all staff. (Previous timescale of 11/01/05 not met. Clarence House E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 E53 S40534 Clarence House V225147 280405 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!