Inspection on 04/01/07 for Clarendon Beechlands

This inspection was carried out on 4th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clarendon Beechlands 08/12/05

Clarendon Beechlands 14/07/05

Clarendon Beechlands 16/11/04

Clarendon Beechlands 18/05/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

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

CARE HOME ADULTS 18-65 Clarendon Beechlands 28 Central Avenue Clarendon Park Leicester Leicestershire LE2 1TB Lead Inspector Ruth Wood Key Unannounced Inspection 4th January 2007 01:15 Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 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 Clarendon Beechlands DS0000006306.V325856.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 Adults 18-65. 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. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarendon Beechlands Address 28 Central Avenue Clarendon Park Leicester Leicestershire LE2 1TB 0116 2703968 0116 2703968 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Ms Mary Crane Care Home 16 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (16), of places Physical disability (9) Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers. No person falling within categories PD or LD may be admitted to the home unless that person also falls within category MD - ie dual disability. Service User Numbers. No person falling within categories MD/PD may be accommodated in the home when 9 persons of category MD/PD are already accommodated within the home. Service User Numbers. No person falling within categories MD/LD may be accommodated in the home when 6 persons of category MD/LD are already accommodated within the home. No person in the category PD to be accommodated in the ground floor bedroom known as 1A. 8th December 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Clarendon Beechlands is a residential care home for 16 adults with mental health problems, learning difficulties, and physical disabilities. It is located in the Clarendon Park area of Leicester City, and is within walking distance of a range of amenities. The home has two floors and comprises of two communal lounges, a dining room, a large back garden, and single bedrooms; one of which has en-suite facilities. Current fee levels at the home range from £280 to £909 Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday between 1:15 and 6pm. Discussion was held with seven residents, two relatives the registered manager and two staff members. Various records were examined including those relating to the support needs of three people who live in the home, as well as medication, staff recruitment, menu and health and safety records. All communal areas of the building were seen, together with six residents’ bedrooms. How staff speak with and ‘get on with’ the people who live in the home was also observed. What the service does well: What has improved since the last inspection? What they could do better: Some people’s written support plans must be updated so that what is written in them accurately reflects the kind of support that people need and are receiving. Risk assessments about some people’s support needs also need updating. For people who have ‘as required’ medication prescribed, written guidance must be put in place stating under what circumstances it is to be given, who has the authority to give it and when its use should be reviewed. The level of support people need to help keep their rooms clean and tidy should be monitored more regularly to make sure that their comfort &/or hygiene needs are not compromised. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good Good Assessment procedures make sure that clients’ needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the registered manager indicated that clients’ needs were assessed before they came to live in the home. Three clients’ files were examined; these all contained assessment documentation completed by the home’s manager which outlined their needs. Discussion with staff members indicated that they were aware of these needs and how they should be met. The placing social worker’s assessment was also examined for the most recently admitted client together with their Individual Placement Agreement. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good Clients are involved in day to day decisions and are supported to take reasonable risks. Written support plans and risk assessments do not always accurately reflect actual need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three clients’ plans were examined – all contained details as to how their needs should be met and risk assessments relating to particular areas of concern, dependent on their individual needs. During discussion the registered manager and key workers displayed a good understanding of clients’ needs as observed but this did not always correspond to the information documented in care files, some of which was out of date. For example there was no risk assessment in place for managing a client’s physical aggression, which had been clearly identified as an issue at their last Care Programme Approach review. Support plans and risk assessments must therefore be regularly reviewed to ensure that they are an accurate reflection of clients’ needs and detail how those needs should be met. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 10 Staff support some clients to manage their finances whereas others are independent in this area. Discussion with clients indicated that they were supported to take decisions about their lives. Some clients choose not to attend any formal daytime activities for example, and there are sufficient staff on duty during the day to enable them to be supported at home. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good Clients have opportunities to engage in vocational, leisure and community activities, are given good support in maintaining links with family and friends and enjoy good, nutritious food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with clients indicated that they could choose whether to attend formal daytime activities (which some do) or whether to spend their time in the home or using local facilities. Staffing levels ensure that there is sufficient time to support clients with their social and cultural needs and staff and clients were observed to relax and chat to each other following the evening meal. Good systems and practice are in place to ensure that clients are able to maintain links with their families. During the inspection, two relatives visited and commented that they had a good relationship with the staff in the home and the registered manager in particular. They confirmed that they felt able to visit or contact the home at anytime and were kept informed about, and felt included in, the support of their relative. Discussion with the registered manager indicated that considerable effort was made to ensure contact with Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 12 families was maintained; this included regular social events at the home to which everyone was invited. Clients have an individual routine, which is dependent on their interests and abilities. This includes the level of responsibility they hold for housekeeping tasks, including the cleaning of their own rooms. Support with this activity is tailored to individual need, but there was evidence that closer monitoring was required of some clients’ abilities in this area to ensure that their level of comfort and hygiene were not being compromised. Efforts are made to ensure clients have access to the recommended five portions of fruit and vegetables per day. For example fresh fruit salad is frequently made and menu records show that fresh vegetables are routinely served. The main meal is served at lunchtime and is prepared and delivered by Prime Life’s central kitchens. Breakfast, tea and supper are prepared at the home, usually by staff, but some clients are involved in preparing their own food. Discussion with clients about the quality of food, indicated that there was plenty of choice (each of the four people spoken to had eaten something different for tea) and that it was enjoyable. “The food is good” “I’ve no complaints about the food” “You can have what you want.” Some clients choose to eat their meals in their own room but the majority eat in the dining room Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good Clients receive appropriate personal support and their health and medication needs are generally well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal care needs were recorded in support plans and the accuracy of the information was verified by conversation with clients, staff and/or their relatives. A mixture of male and female support staff ensure that clients can be supported by a member of the same sex if this is their choice or if this is deemed to be appropriate. Clients have access to community psychiatric nurses and consultant psychiatrists where required and there was evidence of regular input from these professionals in the clients’ review documentation. Discussion with staff and clients and examination of support plans indicated that clients’ health care needs are well addressed. Plans recorded regular appointments with dentists, opticians and GPs as well as recording when medication levels were reviewed or when someone had been having general health checks. One client administers their own medication; an appropriate risk assessment was in place and the client discussed with the inspector how this is monitored. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 14 The afternoon medication was conducted competently by the staff member who confirmed that they had received appropriate training. This information was confirmed through discussion with the registered manager and examination of the staff member’s training record. Some clients are prescribed ‘as required’ medication but there were no protocols in place stating under what circumstances such medication should be given and by whom. These protocols must be put in place. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good Service users are listened to and systems are in place to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The four clients asked, said if they were unhappy about any aspect of their care they would tell the registered manager and expressed confidence that she would “sort things out”. Clients were observed to have an open and friendly relationship with the manager and she confirmed that if there were any concerns they were usually raised with her although there was a formal complaints procedure. Two complaints made to the registered provider since the previous inspection have been dealt with appropriately. At the previous inspection it was recommended that staff members be given ‘refresher’ training on their knowledge of the protection of vulnerable adults. The manager and staff (with two exceptions) did this training on 17th January 2006. The registered manager demonstrated an awareness of the appropriate protocols and the agencies involved in adult protection. Good staff recruitment practices also ensure that residents are protected (see Standard 34). Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good Clients live in a clean and comfortable environment which meets their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: All communal areas and six residents bedrooms were viewed. All communal areas were clean, well decorated and maintained and clients expressed satisfaction with the level of comfort and space they provided. The majority of clients clean their own bedrooms with staff support and these reflected individuals’ preferences in terms of décor and tidiness. Two bedrooms have laminate flooring because of the specific care needs of their occupants; these were documented in care plans. The sash window in one bedroom did not fully close leaving a small gap. The manager said this would be repaired as soon as possible. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good Clients are supported and protected by well-trained staff and effective recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No staff members (with the exception of the registered manager) currently hold a National Vocational Qualification (NVQ) in care although six staff are currently undertaking this qualification at level 2 and one at level 3. This represents 50 of the staff team. Staff have access to a range of training through the parent company covering such issues as working with people with challenging behaviour, effective communication, and the significance of quality assurance. All staff have a training and development record and certificates were available to confirm attendance at training. Good recruitment systems are in place. Three staff members’ files were examined – all contained evidence of identity, written references and a completed application form showing employment history. Criminal records bureau checks are obtained and names checked against the vulnerable adults register before staff commence employment. Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good Good health and safety practice ensures clients’ welfare is promoted. Good systems are in place to ensure that clients’ views inform the way the service is delivered, monitored and improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager holds a National Vocational Qualification at level 4 in care, together with the Registered Manager’s Award; she also undertakes training alongside her staff team to ensure her knowledge and skills remain up to date. A comprehensive quality assurance audit is undertaken by the parent company, Prime Life and this includes discussion with clients, their relatives and other stakeholders. This identifies areas of strength and ways in which the service can be improved. All aspects of daily life are covered; the Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 19 manager discussed the impact the process has had on the kind of food served in the home and how people’s personal preferences were accommodated. Documentation sent to the Commission prior to the inspection, together with evidence gathered suggests that there is good health and safety practice within the home. Gas, electrical and fire systems are regularly serviced and fire systems are also regularly tested. Staff training files contained evidence (certificates) that staff have attended training in first aid, food hygiene, moving and handling, fire safety and Control of Substances Hazardous to Health (COSH). Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (2) (b) Requirement ‘The registered person shall keep the service user’s plan under review’ Support plans and risk assessments must be regularly reviewed to ensure that they are an accurate reflection of clients’ needs and that they detail how they should be met. 2 YA20 13 (2) ‘The registered person shall 31/01/07 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.’ Arrangements for the administration of ‘as required’ medication must be clearly documented. This information must include under what circumstances this medication is to be given, who has the authority to give it, the name of the person prescribing it and the arrangements for review. Timescale for action 31/01/07 Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 22 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 YA16 Good Practice Recommendations The registered person must ensure that clients’ ability to clean and service their own rooms is monitored, to ensure that their level of comfort and hygiene is not compromised. The bedroom sash window identified at the inspection should be repaired to ensure that it can be fully closed. 2. YA24 Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clarendon Beechlands DS0000006306.V325856.R01.S.doc Version 5.2 Page 24 - 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. 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