Inspection on 29/08/06 for Clarence House

This inspection was carried out on 29th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Clarence House Clarence House 42 Warwick New Road Leamington Spa CV32 6AA Lead Inspector Jean Thomas Key Unannounced Inspection 29th August 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clarence House DS0000040534.V310049.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.V310049.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarence House Address Clarence House 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 Mr Kanagasabai Sivasoruban 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.V310049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. CONDITIONS OF REGISTRATION The Registered Provider shall appoint a suitably qualified and experienced person to manage the care home. Timescale September 2006. 10th April 2006 Date of last inspection 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 ensuite which is currently being refurbished. At the time of the inspection visit the fees charged are in the range £298.00 £420.00 per week and payable in advance by either cheque or standing order. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place on Tuesday August 29th 2006 commencing at 11.00am and concluding at 7.00pm. The visit involved two inspectors. A separate visit made by a pharmacist inspector to look at the management of medication, took place on Tuesday 5th September 2006. • • • • The inspection involved: Discussions with the Registered Manager, manager designate, care manager; four care workers, kitchen assistant, domestic assistant and cook. Observations at a mealtime. Two service users were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. An inspection of the environment was undertaken, and records were sampled, including staff training, health and safety, rotas, complaints and fire records. The inspectors’ spoke with one visitor and two health care professionals about their experiences of the home. • • The inspectors had the opportunity to meet most of the service users and talked to four of them about their experience of the home. The service users were able to express their opinion of the service they received to the inspectors. General conversation was held with other service users, along with observation of working practices and staff interaction with service users. A number of service users experience some degree of cognitive impairment or dementia and are unable to express their views or experiences of the service provided, therefore placing greater emphasis on observations and interaction. 10 questionnaire surveys were sent to service users and relatives. One relative had responded at the time of writing this report. Since the last key inspection on Monday 10th of April 2006, we have received one complaint one allegation of abuse and one concern, none have been received by the home. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 6 The allegation of abuse was referred to social services for investigation and in accordance with the local arrangements for the protection of vulnerable adults. Inspections carried out by the pharmacist inspector in June identified issues of concern pertaining to the management of medication. This matter was also referred to social services. Following an investigation into the allegation of abuse no further action was taken and the outcome of the second investigation has not yet been fully concluded. The concern refers to the safety of a service user who left the home unsupervised. Following an investigation by the manager a risk assessment was carried out and a number of practical steps taken to ensure the safety and security of service users. The outcome of a random inspection visit on Wednesday 24th May 2006 to assess outcomes for service users in respect of five shortfalls identified during the last full inspection failed to identify the improvements necessary to achieve a positive outcome for service users. As a consequence a number of statutory enforcement notices were issued to bring about the improvements necessary to ensure positive outcomes for service users. The Registered Provider has failed to provide appropriate staff training in a number of key areas or to update all service user records so as to ensure assessments and written service user plans accurately reflect their current care needs. Rigorous staff recruitment procedures were not in place so we couldnt be sure service users were safe. Staff were not suitably trained in fire prevention and evacuation methods and procedures and staff and service users could have been at risk of harm or injury. A second random inspection and evidence secured during this key inspection confirm improvements have been achieved in all of the areas listed. However further work is required to ensure care needs are clearly identified and staff have access to information they need to ensure individual care needs are met. What the service does well: Service users said that they liked the food being provided for them and that they had a choice at mealtimes. The food presented on the day of the visit appeared nutritious, well-balanced and nicely cooked. Service users appear to be happy and comfortable in the home and with the people supporting them. They were smart in their appearance, with clothes looking fresh and clean. Bedrooms were neat and tidy and service users are encouraged to bring in their own possessions when they come to live in the home. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? A new format has been devised to record the initial care needs assessment carried out with prospective service users before deciding whether to move into the care home. All service users have had their initial care needs assessed either by social services or by the care manager at the home. A new care planning format has been devised and if used correctly should ensure the staff have all the information necessary to meet the service users’ care needs. A number of improvements in the management and administration of medication were noted. For example, the manager has removed all excess medication from the premises and no longer uses any homely remedies. All medicines are administered from pharmacist labelled boxes and the practice of administering one service users medicine to another appeared to have ceased. Appropriate and safe systems necessary to safeguard service users finances are in place. A number of shortfalls relating to health and safety have been addressed including, checks on portable electrical appliances, the regulation of water temperature and checks to control the risk of Legionella. In order to maintain and promote the safety of service users and based on assessment of vulnerability and risk to individual service users, a number of window restrictors have been fitted. It is pleasing to note that training opportunities for staff are being reviewed and that managers are accessing resources in the local community that can offer support in training and guidance to staff. This includes training in adult protection issues and challenging behaviour. Staff records in general, including recruitment files, were in good order and this is encouraging. Repairs to broken door closures in bedrooms and fitting of window restrictors have been completed since the last visit to the home. Fire safety management has much improved with fire alarms being tested on a weekly basis and staff have undertaken fire drill practice during the daytime and nighttime so that risks over a 24-hour period have been observed. Routine maintenance is now more established than previously seen with regular checks taking place on electrical equipment, hot water temperatures and the management of the risk of Legionella in the home. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 8 What they could do better: Significant gaps were identified in care planning, recording and monitoring care practices. Information held on care plans must reflect the complexity of the care to be provided and provide staff with clear instructions as to how individual needs are to be met. Daily records and monitoring records must also demonstrate how individual care needs have been met, so that we can be sure service users are safe and their care needs met. The administration of medicine was not always as the doctor prescribed and some medicines had not been obtained in time, so service user’s went without medication for a period of time. This had a significant impact on the quality of life of one service user. Further work is necessary to make sure risk assessments are carried out for all service users and suitable preventative care plans developed where required. Menu planning is not seen as important and does not take into account the views or preferences of the service users or the dietary needs of older and frail people. Menus must be available to service users and records held of all food provided. Service users must be given clear choices concerning their day-today life in the home. There is an absence of social and therapeutic stimulation therefore service users are not engaged and do not have opportunity to pursue hobbies or to develop and participate in any new interests. Suitable activities designed to meet the individual needs of service users requiring specialist dementia care are not made available. The Registered Manager must ensure that service users who are being cared for in bed or remain in their room have access to a call alarm facility to summon assistance if required. The Registered Manager must review the current arrangements for cleaning the home and appropriate action taken to make sure all areas of the home are clean and free from offensive odours. Although a new bath and shower have been installed, the home has only one shower facility in use; this is below the acceptable number of bathing facilities. The management must assess this situation and produce a plan on how this can be appropriately dealt with. The environment should take into account and reflect the individual needs of service users and display signage and picture images so as to promote independence and assist with orientation. An annual quality audit seeking the views and opinions of service users their relatives and other stakeholders must be carried out. An internal audit and a copy of the findings must be distributed and displayed in the home. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 9 The registered provider must make sure we are advised of any accident or incident that affects the health or welfare of service users. Health and safety management is weak and is putting the people living and working in the home at risk. Considerable improvement is necessary in the areas of infection control and risk assessment and the manager must access training in the management of health and safety in the workplace so he can be sure that health and safety policy and practice in the home is compliant with current legislation and good practice. A number of areas of concern identified during previous inspection visits to the home remain outstanding. This impacts on the management of the staff and care given. Improvements in these areas are required with urgency: 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 DS0000040534.V310049.R01.S.doc Version 5.2 Page 10 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.V310049.R01.S.doc Version 5.2 Page 11 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): 3 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. Service users and family members have opportunity to visit the home prior to admission. A basic care needs assessment is undertaken but information recorded is insufficient to determine whether the home is able to meet the individuals needs. EVIDENCE: Prospective service users have their initial care needs assessed either by social services or by the care manager from home. In response to shortfalls identified during the last inspection a new and improved assessment format has been devised and used for carrying out the initial care needs assessments of prospective service users. Discussion with the manager evidence all service users have had their care needs assessed prior to moving into the home. Examination of the initial care needs assessments of two service users admitted prior to the last inspection found significant gaps in the information held. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 12 For example oral hygiene, continence management, promoting independence or details of any medication taken had not been included and the assessment of one service user required that a dental visit be made. Examination of documentation and discussion with the care manager evidence arrangements had not been made for this to occur. Two service users spoken with said they couldnt remember if they had visited the home before moving in and one service user said she thought a family member had visited on her behalf. As there have been no admissions since the last inspection we are unable to assess the new care needs assessment tool or comment further on the home’s admission process. This will be looked at again during the next inspection. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 13 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 and 10 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. There is a lack of policies, procedures or guidance to promote good health care. Service users health care is reactive rather than pro-active, ongoing monitoring of health is poor. EVIDENCE: The personal profiles and care records of two service users identified for case tracking were examined. The information held on one care plan using the home’s new care planning tool was generally detailed and more informative but did not provide staff with all the information they need to meet the service users care needs. For example, the care plan had not been reviewed or updated to include: • • • • The service user has sustained an injury (broken leg) and a plaster applied to the service user’s lower leg (knee to toe). Monitoring of the service users condition. When the plaster is likely to be removed. The arrangements for attending the fracture clinic at the local hospital. DS0000040534.V310049.R01.S.doc Version 5.2 Page 14 Clarence House • • • • The arrangements for maintaining personal hygiene and continence management. How any pain or discomfort is to be managed. The arrangements for consultation with a physiotherapist or occupational therapist once the plaster is removed so as to determine how mobility is to be restored. The arrangements for maintaining tissue viability thus reducing the risk of pressure sores developing. The last care review was recorded as 2005. Observations of the service user in her room evidence the injured leg was not elevated and the absence of a footstool indicate the leg had not been elevated since the injury occurred. The service user spent the day in her room without having access to the call alarm facility and had to shout for the staff each time she needed assistance. The second care plan examined had been devised using the previous care planning format and also fails to provide sufficient information or details of how the service users needs are to be met. For example: • • • • • • • • • • • Daily visits by community nurses to provide treatment for a serious pressure sore (grade 4/5). How pressure area care is to be provided or prevention strategy. How nutritional needs are to be met. How continence is to be managed. What monitoring checks are to be carried out. How pain is to be managed. How social stimulation is to be provided so as to avoid social isolation. The arrangements for moving and handling. The arrangements for providing personal care. The absence of guidance and instruction from the community nurses regarding pressure area care. A risk assessment necessary to inform care planning. Details of a wound infection and the treatment prescribed have also been omitted from the care plan. Discussion with community nurses evidence the service user should spend 60 minutes each day sitting out of bed. The 60 minutes should be divided into three so that the service user can spend 20 minutes sitting out at mealtimes. On the day of the inspection the service user remained in bed all day and remained lying down and in a semi-recumbent position while a carer assisted her to eat her food. This practice is unsafe and places the service user at risk of choking. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 15 Some records of pressure area care are held and indicate the service user is being cared for on alternate sides. Observations fail to evidence this occurring as each visit to the service user found her in the same or similar position; thus indicating the service user was not being cared for on alternate sides. The inspector was advised that a hoist is used for transferring. The service users bed is located against the wall and therefore places limitations on staff when assisting with moving and handling. In order to provide assistance safely staff should have access to each side of the bed. Information given directly to inspectors and examination of documentation evidence staff are failing to protect service users from sustaining injuries. For example: • A service user sustained bruising when staff failed to notice her elbows were resting over the side of the arm rest on the wheelchair when manoeuvring the wheelchair through an exit door, consequently the service user sustained bruising when her elbow came into direct contact with the doorframe. One service user requiring pressure area care sustained an injury (skin tear) after staff left her in bed with one leg resting on top of the other. • In order to ensure pain was being managed effectively a prescription for Fentanyl patches was to have been collected from the surgery on Friday August 25 2006. Staff failed to respond and the prescription was not collected until Tuesday August 29 2006. The delay in administering effective pain relief may have increased the distress and discomfort already experienced by the service user. In addition the antibiotic prescribed was not administered at a regular dose throughout the day and some doses were missed with no reason recorded. This may have delayed the treatment of the infection. Discussion with two health care professionals evidence that the care provided falls short of what is required and place service users at risk. For example: • A pressure relieving cushion provided by community nurses and to be used by service user with a serious pressure sore had very clear instructions attached as to how the cushion should be used. During a visit to the home the community nurses found the cushion placed upside down and back to front and being used by someone other than the person it was purchased for. On one occasion the service user who should sit in her chair for 20 minutes at mealtimes was assisted out of bed for breakfast at approximately 09.15am and was still in the chair when the community nurses arrived at 11:30am. • Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 16 Documentation evidenced nutritional screening including weight checks are generally undertaken during the admission process and weight monitored and recorded although not always regularly. Documentation fails to evidence service users have a bath or shower. Two staff spoken with said all service users have a shower and none have a bath. The range and quality of information recorded on some care plans has improved since the last inspection but shortfalls in care planning and daily recording fall short of the standard required to ensure service users needs are met. Examination of documentation evidence a number of new care plans have been devised but it was disappointing to note that the introduction of the new care planning format had not been used to identify the needs of those service users assessed as being at greater risk of not having their care needs met. Instead the care plans of service users who are considered more able were afforded priority. Two service users spoken with said, they were not aware of the information held in their care plan and had not been involved in any review of the care plan. Service users have access to a GP, chiropodist, community nurses and optician, etc. However information held on care plans fail to evidence advice is sought from other healthcare professionals i.e. speech therapist for a service user assessed as requiring a soft diet due to difficulty swallowing or community mental heath nurse for those service users diagnosed with dementia or other cognitive impairment. Improvements were noted in the number of risk assessments carried out, for example a risk assessment had been carried out for a service user at risk of having a seizure. However risk assessments had not been carried out for all situations or activities that may present as a risk to the service users health and safety. For example, taking a shower, dehydration, malnourishment or the prevention of pressure sores. There is evidence that staff in the home treat service users in the way, which respects their privacy and dignity. For example, service users are dressed correctly and toilet and bathroom doors are closed when in use. Staff were heard addressing service users appropriately and using their preferred term of address. Observations evidence service users receiving personal care from staff in private. Two healthcare professionals confirm that personal care and treatments are provided in private. The doors to service users rooms should be closed, unless the service user or their relative request otherwise, in which case this should also be recorded in the service user’s care plan. Service users should be offered a key to their room unless their risk assessment suggests otherwise. When a key is not given the reasons for not doing so should be recorded in the care plan. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 17 Privacy screens are available in double rooms and staff close doors to toilets and service users bedrooms when they were undertaking personal care tasks. All bedrooms were unlocked and freely accessible to anyone in the home. Following a third pharmacist inspection the medicine management had improved but further improvements must be made to make sure the service users needs are fully met. Despite a guarantee that a new trolley would be used to transport medicines to the service users this has still not happened. Staff still carry the medicines to the service users. These cannot be held securely in the event of an emergency. Audits demonstrated that the majority of medicines are administered as prescribed but some doses are still not administered as the doctor intended. Staff do not adequately check the prescriptions before dispensing or the dispensed medication received into the home. This resulted in one medicine being dispensed that had been discontinued. This was recognised once it had been dispensed and had not administered but the medication had not been crossed off the Medicine Administration Record (MAR) chart. Two service users did not receive all their prescribed medication for 10 days before a new supply was sought. A similar problem was highlighted at the last inspection. Some medicines had not been administered and recorded as “O” (other) with no supporting reason. One medicine that had not been administered correctly was an antibiotic, which was administered three times a day for 3 days and not four times a day. This may have delayed effective treatment of the infection. One medicine had been purchased as a homely remedy and administered to the service user. There was no supporting policy to administer it and the staff did not rectify the problem at source and obtain a further prescription for the original medicine that had run out. Some good practices were seen. Staff do record all the medicines received into the home so audits are easy to carry out to demonstrate whether medicines are administered as prescribed. One care assistant interviewed had a good understanding of all the medicines she administered and was keen to improve the practice further in the home. Some staff are enrolled in an accredited course in the safe handling of medicines are due to complete this soon. Medicine was still kept in the home that belonged to a gentleman who lived next door. These had not been removed from the home since the last inspection. The gentleman no longer comes into the home. Medicines should only be kept for the service users who live in the home. This was highlighted at the last inspection. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 18 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 and 15 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home Service users are not supported to make informed choices about daily living activities. Consequently their right to independence and autonomy is restricted. The systems used for service user consultation are poor with little evidence that their views are sought and acted upon. The meals in this home are generally good but may not be catering for the dietary needs of frail and older people. EVIDENCE: The care plans of two service users were examined. Information recorded fails to identify the service users hobbies, interests or religious needs. There is a programme of weekly activities for service users however, this is generally planned and chosen by the staff with service users not being involved or asked how they would like to spend their time. At the time of the visit observations evidence the activities taking place did not reflect what was on the weekly programme although some service users were asked what they would like to do. In the morning one service user participated in a table game with a care worker and another service use completed a puzzle book, which the service user enjoyed. The majority of service users sat in the lounge with the television on throughout the day. A hand massage activity took place in the afternoon for service users wishing to participate. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 19 A record of planned activities is held in a designated book and the last recorded entry was August 16 2006 when some service user took part in a Music and Movement activity. Staff spoken with said the record book had only recently been introduced and they had not all been aware of the new procedure and had continued to record events using the previous format. This was not available for examination. It is recommended that trips out to the local shops should also be recorded. In response to shortfalls identified during the last inspection an activity programme has been devised but there is no evidence of consultation with service users to ascertain how they would like to spend their time or identify past hobbies or interests, therefore we cannot be sure the individual or collective needs of service users will be met. Further work is necessary to make sure appropriate activities are available for service users with dementia. The activity programme does not include the use of items for promoting mental agility or encourage finer dexterity skills both of which can be beneficial for individuals with cognitive impairment or dementia. Staff sometimes accompany a service user to the shops, details of when these outings occur are not recorded on the daily records. Observations evidence some interaction between staff and the service users but not all staff interact in a manner that is engaging or requires a response. A number of individual life histories have been developed but have not yet been transferred to the care plan for daily use. Signage and pictures should be used to aid orientation around the home. Representatives from St Marys Church visit the home each Sunday to offer Communion. The home has no other community links. The home has a flexible visiting policy and visitors to the home are made welcome. Two service users spoken with expressed satisfaction with the service provided. Comments made directly to the inspector include: • They cant do enough for you they are so kind. • Food very nice, have fresh fruit but sometimes we have to buy it ourselves. • I can get up and go to bed when I like, but I do need someone to help me. • I dont do any activities. • I sometimes go out shopping on the parade. A number of service users spoken with have some degree of cognitive impairment or dementia and are unable to express their views of the service provided to the inspectors. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 20 At lunchtime service users were offered a choice of roast chicken, cabbage, carrots and potatoes or fish, chips and mushy peas followed by rhubarb crumble and cream or jam tart and custard. There are no menus and decisions about what food is to be provided is made by the staff and not always in advance. At tea time the meal was prepared by the care staff and service users were offered beans on toast or egg mayonnaise sandwiches. Examination of the care plan and daily records of one service user assessed as requiring a specialist diet fails to evidence assessments necessary to determine nutritional needs or the service user’s ability to swallow have been carried out, or of any consultation with a dietician, speech therapist or other health care professional to determine dietary needs. The nutritional needs of service users are not always accurately reflected in the care plans. For example, one care plan examined did not include the need for a liquidised diet. Observations in the dining room and lounge area at lunchtime evidence sufficient numbers of staff available to provide the support and assistance needed by service users to eat their food. Observations evidence one care worker assisting a service user to eat her food in a sensitive and caring manner. Service users are not asked what foods they like or dislike as part of the care planning process but the staff generally offered alternatives. Service users spoken with said that they had been given a choice at lunchtime and one service user said they had “chosen the fish to day rather than the meat”. A record of meals taken is recorded on each individual service user’s daily record sheet. Food is plated rather than provided in serving dishes from the table, a practice that would promote individual choice, independence and dexterity. Drinks were provided through the day for those people in the lounge area. Comments received from a relative expressed concerns that their family member might not always get drinks brought to them when they had to spend long periods in their bedroom. Some aspects of staff practices are considered to be inappropriate or unsafe for example: • • • Food taken around the home is uncovered. Two care workers remained standing while assisting service users to eat their food. This is considered poor practice and should be discouraged. One service user being cared for in bed and having a liquidised diet was assisted to eat her food while laying down in a semi recumbent position. This is practice is unsafe and may place the service user at risk of choking Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 21 At meal times service users in the dining area have access to soft disposable wipes or other protective clothing necessary to maintain dignity, but observations of a service user being cared for in bed evidence a carer using a paper hand towel to remove food from the service user’s face. This could result in discomfort and is undignified and therefore inappropriate. The food served was generally attractive, nutritious and plentiful, but the absence of effective monitoring and recording of dietary intake of those service users assessed as being at risk may lead to malnourishment. The food stocks at the home were in adequate supply as a delivery had just been received. A variety of foods was stored which included dry goods, fresh and frozen meat and vegetables. Dried foods were found to be stored well in a clean area and food in freezers and fridges was generally being stored safely although pre-cooked foods must be dated if frozen or being stored in the fridge for use at a later date. Daily temperatures of fridges and freezers are recorded so that the home can be sure food is constantly stored at a safe temperature. Examination of documentation and discussion with the care manager evidence care staff have attended training in safe food handling but the cook who was not at work at the time missed the training course. Arrangements have been made for the cook to attend food safety training in September 2006. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 22 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 and 18 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. The service has a complaints procedure that falls short of meeting the national minimum standards and regulations. The policies and procedures regarding protection of service users are adequate, but the absence of appropriate staff training in the area of protection is unsafe and place service users at risk. EVIDENCE: The home has a complaints procedure, which is displayed, in some service user’s rooms. Information held in the document requires revising to include a timescale not exceeding 28 days for responding to complaints so that service users know their concerns are taken seriously and will be responded to appropriately. It is also recommended that details of the procedure be displayed in a prominent position in the home so that visitors also have access to the information they need should they wish to complain. Since the last inspection the home has no recorded complaints. We have received one allegation of abuse, one concern and one complaint. The allegation of abuse was referred to social services for investigation and in accordance with the local arrangements for the protection of vulnerable adults. An inspection carried out by the pharmacist inspector identified issues of concern pertaining to the management of medication. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 23 This matter was also referred to social services. Following an investigation into the allegation of abuse no further action was taken and the outcome of the second investigation has not yet been fully concluded. The concern was about the safety of a service user who left the home unsupervised. Following an investigation by the manager a risk assessment was carried out and a number of practical steps taken to ensure the safety and security of service users in the home. The complaint was anonymous and raised concerns relating to: • Lack of induction training for staff. • Breach of confidentiality by staff and poor care practices i.e. moving and handling. • Staff working long hours. • Poor food and hygiene practices and absence of information on meals offered to service users - no menus and environmental issues. These issues were looked at during the inspection and the outcome is as follows: • A new programme of staff induction has been devised but has yet to be implemented. • There is no evidence of any breach of confidentiality by the staff but there is evidence that personal and confidential information relating to service users is not stored safely or securely. • Shortfalls were noted in the methods used by staff when assisting service users with moving and handling. • A number of staff work long and what may be considered to be excessive hours. • Poor food and hygiene practices were found during inspection visits carried out by the Environmental Health Officer between June - August 2006. • Service users do not have access to information about meals and menus are not available. Staff spoken with advised that adult protection training, (PoVA), was planned to take place on 24th of August 2006 but due to the absence of sufficient numbers of staff necessary to meet the service user’s needs while the training took place the training was cancelled. We were advised the training is be rescheduled although this has yet to be determined. Observations of interactions between service users and staff evidence service users generally have good relationships with each other and with those who support them. Staff however must be mindful of their role and responsibility in safeguarding service users from harm and this includes having an understanding of the mental health care needs of service users when this has the potential to cause harm to others. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 24 For example, two service users were overheard having a conversation with each other which over a period of approximately 15 minutes which changed from being friendly to one of the service user becoming very upset and verbally aggressive toward the other. At this time there was only one staff member in the room who did not offer support however, they may not have been fully aware of the content of the conversation, or the support strategies necessary, as they were newly recruited and English was not their first spoken language. This incident had the potential to place both service users and the staff member at risk There is no evidence on care plans or through discussion with staff that the support and guidance of mental health services is being sought during the care planning and risk management processes. In response to shortfalls identified during the last full inspection there is evidence that training in the management of challenging behaviour has been arranged to take place on October 13 2006. The course content information shows that this training will include advice and guidance to staff on diffusing situations and understanding behaviours that challenge. It was advised by senior staff that crisis prevention and intervention training is also to be arranged at a later date for senior staff and this is recommended as a good practice development. In response to shortfalls identified during the last inspection the policy and procedure for the protection of vulnerable adults has been reviewed and revised to include ’whistle blowing’. One staff member spoken with understood the main principles of the ’whistle blowing’ policy and procedure and another wasnt aware of the procedure and said she would raise any concerns with the manager. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 25 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, 21, 24 and 26 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. The environment is in need of some refurbishment and redecoration. There are insufficient bathing facilities to meet the identified needs of service users. Management of the prevention and control of infection is poor and place service users’ health and well being at risk. EVIDENCE: Service users said they were comfortable and many areas of the home were generally warm and tidy. The dining area although having no external aspect, has good quality dining room furniture. Shared areas of the home are relatively clean although some seating in the lounge is very worn and should be replaced. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 26 Eight service users bedrooms were viewed including those of the two service users whose care was being examined in detail. Beds had been made and the bed linen was fresh although a bed not being used in one of the shared bedrooms was unmade which may not be pleasing for the service user still using the room because. Shortfalls identified during the last inspection include the repair of a curtain rail in a service users bedroom, observations evidence this remains outstanding. It is evident that service users are encouraged to bring their own possessions when they come to live in the home and photos of family members were on display in all the bedrooms viewed. Clothes are folded and stored neatly and appropriately in wardrobes and drawers. Bedrooms with washbasins have screening for privacy. It was noted however that hand towels and flannels were not provided. There are odour control issues in three of the bedrooms viewed. Commodes are provided in all bedrooms and many of these are in poor condition with bowls being heavily stained. The commode chairs are not in a style that is discreet or in keeping with a homely environment and the manager should consider replacing them with style that promotes dignity for service users who may receive visitors in their bedrooms, for example, armchair commodes. Service users who are able to can move around the home freely and were seen to do so. Four service users in the lounge however were dependent on staff support to move around the home and were seen to spend most of the day in the same chair in the lounge from breakfast and were still there at 7pm when the inspection was concluded, only moving when supported by staff to the bathroom which is just off the lounge area. This was observed to be generally after each meal. A good practice recommendation was discussed with the manager for reviewing the location of the dining area to the front of the house and therefore providing a larger lounge area and greater access to natural light. This would encourage and aid mobility and offer a view of outside activity on the main road at the front of the house. There is a conservatory leading off from the lounge, which overlooks the back garden however this is not easily accessible to all service users and only one was seen to use this area and that was for smoking purposes. Staff use this room for smoking and a rest area. If the conservatory were made more accessible for all service users this again would offer a different view for those with limited mobility. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 27 The management of the control of infection in the home is poor in the areas of laundering soiled linen, cleaning commodes and disposal of incontinence pads and clinical waste. Examination of care plans identified there had been an outbreak of diarrhoea in the home during August 2006 and that a pressure sore had become infected and these dressings would be included in continence waste disposal. The washing machine had not been working for six days and the manager didnt know when work to repair the machine would be carried out. In the absence of a washing machine all laundry including soiled linen is being washed at a local launderette. This arrangement is unsatisfactory, as the facilities at the launderette may not ensure that the soiled linen was being washed at the hot water temperatures necessary to manage the risk infection or cross contamination. This shortfall resulted in an immediate requirement notice being issued that this practice cease and suitable arrangements be made for soiled linen to be washed appropriately and by an industrial laundry service. The manager contacted the washing machine lease contractors who advised that they would visit to repair the following day. Two staff were asked about the procedure for cleaning commodes and their responses suggest that infection control procedures are not clearly understood by the staff team as commodes are washed by care staff on a daily basis using a bucket and cloth or the commode bowls are washed in a bath after emptying the contents down the sluice. Observations of the sluice suggest it is seldom used and this was confirmed in discussion with another staff member who said that the sluice was only used for storing incontinence waste in yellow bags. The main storage facility for continence waste is located outside and was found to be inadequate for the amount of clinical waste and incontinence pads generated by the home. The container was full and overflowing with bagged waste and a further eight bags were on the ground next to the container. The manager advised that one container is usually satisfactory for the amount of waste in the home, which is contracted to be collected at two-weekly intervals, however the company contracted to do this had not been to the home for three weeks. The manager phoned the contractor and was advised the waste would be collected the following day. Waste bins in service users bedrooms, bathrooms and toilets did not have close fitting lids and were being used for the disposal of paper towels and continence pads. Observations evidenced a soiled continence pad left in a waste bin in a service user’s bedroom for at least five hours. The service user was sitting in the room next to the open bin and may have felt embarrassed by what she could see and by any odour generated as a result of poor staff practices. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 28 The poor management of the prevention and control of infection and disposal of continence and clinical waste poses a potential risk to service users and staff and resulted in two immediate requirements being made to ensure improvements are made. There had been no progress in the refurbishment of the ensuite bathroom and the reasons for this were discussed with the manager. The inspector was advised that estimates have been obtained for the refurbishment but work delayed while the manager reviewed the bathing facilities in the home. The manager said he is considering whether the facility should continue as an ensuite or relocate the entrance from the bedroom to the main corridor so that other service users can use it. As required the manager has discussed possible changes to the environment with an inspector responsible for registration and variations, and is aware approval for any changes to the environment must be sought. As completion of the refurbishment has been delayed for a significant period of time it was agreed with the manager that the refurbishment of the ensuite should continue and if at a later date the manager feels the need to change this facility he will consult with the commission further before any changes are made. In response to shortfalls identified during the last inspection the ensuite room has been made secure and a risk assessment carried out. The home has only one bathroom and one shower room and the absence of suitable equipment in the bathroom means that service users are unable to use this facility. Daily records examined do not determine whether service users are having access to the shower for personal care therefore it is not possible to determine whether personal hygiene needs are being met appropriately. The shower facility is in poor condition, although a new and safer shower chair has been provided for service users to use. The shower floor and surround is in a poor state of repair and cannot be cleaned effectively and therefore poses a risk of infection or cross contamination. An armchair has been placed by the washbasin in the shower room for service users to sit at when being washed and dried, the armchair is not of a washable material and is heavily soiled, again this does not promote effect infection control measures. Talcum powders, shampoos, razor blades and combs in a box were on the window ledge in the shower room, suggesting communal use and therefore posing a potential risk to service users. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 29 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 and 30 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. The service does not support or encourage the development of a competent staff team in key areas. Training provided is very limited, with areas not being identified and not targeted at relevant individuals. Training provided will tend to be internal, but there is now a willingness to seek external providers to deliver training. EVIDENCE: On the day of the inspection there are 15 service users accommodated at the home with a staff complement comprising of the Registered Manager, care manager, manager designate, three care workers, cook and domestic assistant. On the afternoon and evening shift there is the care manager and two care workers on duty until 8pm and the care manager and one carer until the night staff arrive and 9 p.m. Two care workers provide support and assistance for service users at night. It is still not clear on staffing rotas as to the designation of each staff member or whether the staff member is working a day or night shift. The staff rota also evidences that staff continue to work long hours or a day shift followed by a night shift. For example, on August 27 2006 two staff completed a dayshift followed by a waking nightshift with one working through from 5pm August 27 to 8am August 28 (15 hours). On August 28 one staff member worked 11am 9pm (10 hours). Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 30 Information held on the staff rota does not accurately reflect the number of staff on duty. For example in one instance the rota identifies only two carers as being on duty for a day shift and the care manager states there were three carers on duty. The time spent in the home by the Registered Manager is still not being recorded as required by the Care Homes Regulations 2001. Two staff members spoken with said there were generally sufficient numbers of staff on duty but providing cover for absent colleagues could be difficult. Observations evidence sufficient numbers of staff on duty on the day of the inspection but shortfalls were identified in the way staff are managed and deployed. For example there is not a designated carer responsible for attending to the individual care needs of service users who remain in their room or who are being cared for impaired. There are times when some of the staff appear to have little or nothing to do and were observed watching television or sitting in the conservatory talking to colleagues. In discussion the Registered Manager said the manager designate is to be responsible for devising the staff rotas and for ensuring there are sufficient numbers of suitably qualified and experienced staff available to meet the needs of service users. Since the last inspection one of the two domestic assistants employed has left the home and an appointment to this vacancy has not yet been made. There is clear evidence that some progress is being made in identifying a staff training and development programme and that this is being done using the resources of local colleges and training enterprises, including Warwickshire Social Services. There is however no confirmed dates for future training other than challenging behaviour and fire training for staff. A review of staff qualifications and training is being documented and individual staffing files put together. Future training needs have been identified by the home as necessary in dementia care, abuse and communication. An induction process has been identified but has yet to be implemented however, staff members spoken with said they had received a basic induction on the first day of working in the home which had included being shown how to use the hoist, although they could not do so until they have the necessary training, and being made aware of the service users bedroom locations. The staff member said discussion had taken place with managers about achieving a National Vocational Qualification (NVQ) level 2 in care. The Care Manager is an NVQ Assessor at level 2, one carer has NVQ level 2, two carers are nearing completion of NVQ level 3 and a further six are working towards achieving the level 2 award. This falls below the expectation that a minimum of 50 trained care staff at NVQ level 2 is achieved by 2005, excluding the manager or care manager. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 31 The recruitment records for new staff were examined and it was found that the security checks necessary to ensure the safety of service users had been carried out before the worker was confirmed in post. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 32 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): 31,32,33,34,35,36,37 and 38 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the home. Training, development and supervision of staff is inconsistent and staff lack leadership. Quality assurance monitoring is not regarded or implemented as a core management tool. The home is drifting and lacks purpose and direction. EVIDENCE: The Registered Manager is not qualified, has only basic management skills and minimum experience to run a care home. It has been agreed with the providers that the Registered Manager be replaced by a qualified and experienced person to manage the care home. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 33 A manager designate for the role has been appointed and is to submit an application to be the Registered Manager. Following the registration of a suitable manager the current Registered Manager, who is also one of the owners, plans to continue working in the home but will not have day-to-day responsibility for the operational management of the home. The home currently accommodates 16 service users one of which is being cared for in hospital. This leaves the home with five vacancies and with social services currently choosing not to refer service users to the home there is a possibility that occupancy levels could reduce further. Issues surrounding the financial viability of the home were discussed with the Registered Manager/owner. The manager reported he has a financial management strategy and providing the home can evidence improvements in the standard and overall quality of care provided to service users the home would continue to be financially viable. The Registered Manager/owner must advise the commission immediately if the financial position is not deemed to be sustainable in the longer term. Prior to the inspection visit we received a complaint that staff fail to maintain service user confidentiality. Discussions with staff and observations during the visit found no evidence of a breach in confidentiality. However observations evidence service users personal record files are stored in separate two cupboards in communal areas of the home. Only one of the two cupboards is fitted with a security lock. On the day of the inspection both cupboards were left open, unattended and information made easily accessible. Therefore we cannot be sure information held is either safe or secure. It was noted that staff use a ‘handover book’ to share information. The individual names of service users’ and details of their personal circumstances are recorded in the book. In order ensure the security of information and compliance with the Data Protection Act 1998, documentation relating to individual service users must be stored on their personal record files and facilitate the home’s access to records policies and procedures. Arrangements to introduce a formal staff supervision system are in place but have yet to be implemented. The manager said that informal discussions take place in the form of team meetings however these have not been documented and could not be evidenced. The home does not have a written policy or procedure for safe guarding service users finances. In response to shortfalls identified during the last inspection visit improvements have been made in the way records are managed and maintained. Individual records of all financial transactions and of money held on behalf of the service user are held and maintained and receipts issued when money is deposited for safekeeping. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 34 Individual receipts confirming expenditure on chiropody, hairdressing and other personal items purchased on behalf of service users are also held. Independent professional advocacy services support three service users with managing their finances and the remaining service users either manage their finances independently or are supported in doing so by family members. No property is being held for safekeeping. Health and safety management continues to be weak however there is some improvement in maintaining records and necessary for demonstrating compliance with Health and Safety legislation. Records relating to fire safety were examined and found to be up-to-date, this included the testing of alarms and fire drill practices. The manager must be mindful that new people coming to work in the home must become familiar with fire safety procedures in the home and to document that they have understood this. In response to shortfalls identified during the last inspection a number individual risk assessments necessary to determine the safety of service users have been carried out and in response window restrictors have been fitted in a number of service user’s private rooms. The service continues with its maintenance checks for heating and boiler servicing and moving in handling equipment. There is satisfactory regulation of water temperatures and the risk of Legionella is monitored and controlled. Small portable electrical appliances are routinely tested for continuing safety. In response to shortfalls identified during the last inspection access to the laundry room (in the cellar) is by a key code entry system and chemicals and cleaning products are stored securely in a locked cupboard in the laundry room. There is no information displayed for staff on the use of chemicals and cleaning products in the home and this includes the COSHH information. One staff member spoken with said she was unaware of COSHH and had not had any training on the safe use of cleaning chemicals. The home failed to advise us of incidents in the home that impact on the health and welfare of service users and in accordance with regulation 37 of the Care Home Regulations. This includes an outbreak of diarrhoea during August 2006, disruption in the electricity supply in part of the building and the breakdown of the washing machine. Staff working in the kitchen were observed wearing aprons but did not wear a hat necessary for ensuring hair doesnt fall onto food preparation areas or get into food. Other staff did not always wear protective clothing when entering the kitchen and food preparation areas therefore practices remain unsafe. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 35 The findings of this inspection highlighted serious concerns in the management of infection control practice and procedure and it is disappointing that the manager has not undertaken training in Management of Health and Safety in the workplace as required following the last full inspection of April 10, 2006. Without this knowledge it is difficult to see how the manager can ensure the protection to people living and working in the home through safe working practices. Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 36 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 1 X X 2 X 1 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 2 3 1 1 1 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 37 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The Registered Provider must ensure that a full pre-admission assessment is carried out on all prospective service users to ensure that their needs can be met. The Registered Provider must ensure that care plans are current and set out in detail each service users health, personal and social care needs. Care plans must be regularly reviewed and updated to reflect any change in needs or circumstances. Service users must have access to appropriate community health care professionals and facilities. (Outstanding from April 06) The Registered Provider must ensure risk assessments are developed on an individual basis and include any activity that may pose a risk. (Outstanding from April 06) Where a risk is determined a care plan must be devised describing the action to be taken to minimise the risk. DS0000040534.V310049.R01.S.doc Timescale for action 30/09/06 2 OP7 15 30/09/06 3 OP7 13 30/09/06 Clarence House Version 5.2 Page 38 4 OP8 13 5 OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) Accurate and effective monitoring records must be held and clearly identify how service users care needs are being met. The Registered Provider must make arrangements for service users to receive where necessary, treatment, advice and other services from any health care professional. (Outstanding from April 06) The Registered Provider must review the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines in the home. (Outstanding from January 06) This requirement was not assessed during this inspection and the timescale for compliance is 19/07/06. The Registered Provider must install a system to check the prescription prior to dispensing and the dispensed medicines and MAR chart received into the home. (Outstanding from January 06) Action must be taken to ensure that all the service users prescribed medication is available to administer at all times and the MAR chart reflects the current drug regime. The Registered Provider must ensure that the MAR chart reflect exactly what has occurred. Reasons for nonadministration must be recorded. 30/09/06 30/09/06 30/09/06 30/09/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 39 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP9 13(2) The Registered Provider must ensure a homely remedy policy is written for all medicines the staff wish to purchase and administer as a homely remedy. The Registered Provider must ensure a trolley is used to transport medicines to the service users in a safe manner. The Registered Provider must ensure care staff order medicine that the service users require in time to ensure that there is enough medicine to administer as prescribed. (Outstanding from January 06) The Registered Provider must ensure any when required medicine must be supported by a prn protocol written with the support of a clinician. (Outstanding from January 06) The Registered Provider must ensure that all care staff that handle medicines undertake an accredited course in the safe handling of medicines. Timescale partially met 06/07/06. The Registered Provider must ensure that the medicine refrigerators maximum, minimum and current temperatures be read daily and must lie between 2°C and 8°C at all times to ensure the stability of medicine requiring refrigeration within in accordance with their product licences. Appropriate action must be taken if the temperatures fall outside these limits. (Outstanding from January 06) DS0000040534.V310049.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 Clarence House Version 5.2 Page 40 14 OP9 13(2) This requirement was not assessed during this inspection and the date for completion is 19/07/06. The Registered Provider must undertake staff drug audits before and after a drug round to confirm staff competence in medicine management. The Registered Provider must take appropriate action if these audits indicate that staff are not administering the medicines as prescribed and accurately recording the transaction. (Outstanding from January 06) The Registered Provider must ensure service users have opportunity to exercise their choice in relation to leisure and social activities. (Outstanding from April 06) The Registered Provider must ensure safe feeding practices and not feed service users while they are lying down and in semirecumbent positions. (Timescale of 14/09/06) The Registered Provider shall ensure that pre-cooked foods stored in the fridge or freezers have the date they were stored recorded. The Registered Provider must ensure the complaints policy and procedure includes the timescale for responding to complaints and which must not exceed 28 days. Information on how to complain must be displayed in a prominent position in the home. 30/09/06 15 OP12 12(3) 30/09/06 16 OP15 13 30/09/06 17 OP15 16(2)(j) 30/09/06 18 OP16 22 30/09/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 41 19 OP18 18(1)(a 20 OP18 13 21 OP18 18 22 OP20 14(1) 23 OP21 23(2)(j) The Registered Provider must ensure that the number and skill mix of staff ensure that service users’ care needs, including mental healthcare, are understood and supported at all times. The Registered Provider must ensure that physical and/or verbal aggression by service users is understood and dealt with appropriately, and that physical intervention is used only as a last resort and in accordance with Department of Health guidance. (Outstanding from April 06) The Registered Provider must make arrangements by training staff to prevent service users being harmed, or suffering abuse as part of a risk management strategy. Staff must receive training on Adult Protection and the Management of Challenging Behaviours and Restraint. (Outstanding from April 06) The Registered Provider must ensure that seating in the home, including the lounge areas, is designed to meet the collective and individual assessed needs of service users. Outstanding from April 06) The Registered Provider must ensure that the people living in the home have toilet, washing and bathing facilities sufficient and suitable to meet their identified needs. (Outstanding from April 06) The Registered Provider must ensure the bowls used in toilet commodes are replaced with new. 30/09/06 30/09/06 31/10/06 31/10/06 31/10/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 42 24 OP22 12(1) 25 OP24 23(2)(b) 26 OP24 12 27 OP26 16(2)(j) The Registered Provider must ensure service users have easy and safe access to a call alarm. (Outstanding from April 06) The Registered Provider must make arrangements for the repair of the broken curtain rail in the downstairs front bedroom. (Outstanding from April 06) The Registered Provider must ensure service users are provided with a key to their room unless their risk assessment suggests otherwise. (Outstanding from April 06) The Registered Provider must ensure that systems are in place to prevent and to minimise any risk of infection including: • A policy and procedure for the prevention and control of infection. • Ensuring hand washing facilities, (soap dispensers), are available. • The laundry floor finishes must be impermeable. • Equipment used in bathroom and toilet facilities is washable and also in good order. (Outstanding from April 06) The Registered Provider must ensure additional safety measures to be introduced include: • The effective disposal of clinical waste and used incontinence pads. • Effective and appropriate cleaning and sterilization of toilet commodes. • The staff practice of using communal soaps, deodorants, razors and hairbrushes must cease. 15/09/06 31/10/06 31/10/06 30/09/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 43 28 OP26 16(2)(J) 29 OP26 16(2)(k) 30 OP27 18 Schedule 4 31 OP30 18 32 OP30 18 The Registered Provider must ensure that in the absence of a washing machine soiled linen must be laundered in accordance with health and safety requirements i.e. an industrial laundry service with facilities to safely launder soiled linen at the required water temperatures. (Timescale of 31/08/06) The Registered Provider must make arrangements for the removal of excessive clinical and incontinence waste left on the ground outside and next to the waste container. (Timescale of 05/09/06) The Registered Provider must include details on the staff rota of the time spent in the care home and the designation of each staff member. (Outstanding from April 06) The Registered Provider must ensure new workers have an induction appropriate to the role they are to perform and records held of: • Any shadowing of an experienced worker or mentoring. • Training on the principles of care, safe working practices, the workers role, the experiences and particular needs of the service users. The Registered Provider must provide a written staff training and development programme for 2006/07. A completed staff training matrix must be forwarded to the Commission. This should include induction, NVQ and mandatory training. Outstanding from April 06) 30/09/06 30/09/06 30/09/06 30/09/06 31/10/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 44 33 OP33 24 34 OP35 25 35 OP36 18 36 OP37 17 37 OP37 17 The Registered Provider must establish and maintain a system for reviewing and improving the quality of care provided at Clarence House and shall supply the CSCI a report in respect of any review. (Outstanding from April 06) The Registered Provider must advise the Commission immediately if the financial position of the home is not deemed to be sustainable. The Registered Provider must establish a formal staff supervision programme to be implemented on a regular basis for each staff member and records of the supervision be held. (Outstanding from April 06) The Registered Provider must ensure all policies and procedures are reviewed and are in line with current good practice and confidential information relating to service users must be held safely and securely. (Outstanding from April 06) The Registered Provider must ensure individual records are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. The Registered Provider shall ensure that all records, in respect of the service provision, are kept secure, up-to-date and in good order and readily available at all times for inspection in the care home by any person authorised by the commission. Outstanding from April 06) 14/12/06 16/09/06 31/10/06 31/12/06 05/09/06 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 45 38 OP38 37 39 OP38 23(5) 40 OP38 10(3) The Registered Provider must 14/09/06 inform the CSCI of any accidents or incidents effecting the health or welfare of service users. (Outstanding from April 06) The Registered Provider must 30/09/06 ensure that all persons accessing or working in the kitchen area wear protective clothing (aprons and hats) at all times. Outstanding from April 06) The Registered Provider must 31/10/06 undertake accredited training in the Management of Health and Safety in the Workplace. (Outstanding from April 06) Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 46 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. Refer to Standard OP15 OP19 Good Practice Recommendations The staff should sit down with service users when assisting them to eat their food. It is recommended that a suitably trained and competent person carry out an assessment of the environment to ensure service users have access to appropriate equipment and adaptations necessary to maximise independence and to promote safety throughout the home. The Registered Provider should produce a programme of routine maintenance and evidence of renewal of the fabric and decoration of the premises. The programme should include costing and implementation. Staff should not work what may be considered to be excessive hours, as this may impact on the health, safety and welfare of service users and the staff. The care manager should complete an NVQ level 3 in care or equivalent. Regular team meetings should be introduced so as to encourage cross-fertilisation of ideas 3. 4. 5. OP27 OP29 OP36 Clarence House DS0000040534.V310049.R01.S.doc Version 5.2 Page 47 Commission for Social Care Inspection Leamington Spa Office 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. 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