Inspection on 02/03/06 for Clarendon Care Home

This inspection was carried out on 2nd March 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clarendon Care Home 23/10/08

Clarendon Care Home 25/10/07

Clarendon Care Home 29/03/07

Clarendon Care Home 21/07/05

Clarendon Care Home 20/12/04

Clarendon Care Home 27/09/04

Clarendon Care Home 20/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Clarendon Care Home 64/66 Clarendon Road Southsea Hampshire PO5 2JZ Lead Inspector Mark Sims Unannounced Inspection 2nd March 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 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. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clarendon Care Home Address 64/66 Clarendon Road Southsea Hampshire PO5 2JZ 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) 023 92824644 023 92824644 alicedunbar@madasafish.com Mrs Alice Dunbar Mrs Alice Dunbar Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: Clarendon Rest Home is a large property situated within reasonable walking distance of the town centre of Southsea, and within a few minutes walk of the seafront and pier. Accommodation provided is by way of eight single bedrooms, one of which has an en-suite facility and six double bedrooms, four of which have an en-suite facility. Day space within the home is provided for by way of two lounges and a separate dining room. Outside there is an attractive garden, which consists mostly of patio area with flower borders and planting boxes. The home is registered to accommodate twenty elderly persons, of either sex, in need of residential care due to old age and related mental health problems. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken unannounced and formed the second statutory inspection of the year for Clarendon Care Home. The inspection focused on those core standards not addressed at the 21st July 2005 inspection and various sources of evidence were considered in the formulation of judgements: records, observations and discussions with service users and staff/management. What the service does well: What has improved since the last inspection? A number of requirements were made during the last inspection, 21st July 2005, and efforts to comply with these requirements include: • The manager was required to complete a relevant management qualification as she possessed no formal qualification. In response to this requirement the current manager has decided to stand down (as she is also the proprietor) and has submitted an application seeking the registration of the deputy manager, as she possesses the relevant qualification. The home was required to seek infection control advice around the handling of soiled laundry. The deputy manager confirmed that advice had been sought and that as a consequence of the advice provided the home now possessed a range of bags used with waste materials, red bags for use with the laundry. DS0000039959.V279565.R01.S.doc Version 5.1 Page 6 • Clarendon Care Home • The home was required to address the issue of how they intend to seek the views of the service users and those parties involved in the home. In response to this requirement the manager has located a satisfaction survey that is intended to be used with clients, their visitors and professional bodies. What they could do better: A number of issues were raised with the management team as requiring attention and included: • The need to review the assessment tool used by the home, as it is imperative that the information gathered is used to underpin and/or inform the care planning process. The risk assessment tool used by the home should be reviewed, as the home is not a nursing home and therefore rather than using complicated nursing assessment systems, the home should keep their risk assessment strategy simple, identifying the action or concern, the level of risk, how likely the risk is to occur and a plan for managing or monitoring the risk. A review of the personal allowances (held for service users by the home), revealed that staff are not double signing transactions, which should be carried out in accordance with best practice guidelines. The premises should be risk assessed, as it is both a place of work and a place of habitation. The management team must ensure people realise the kitchen cannot be used as a short cut to the laundry and that items that require laundering should be taken to the external laundry by a more appropriate means. • • • • 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. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. The management team is undertaking assessments prior to admission however, the assessment information is not being collected in a structured way that enable people’s care needs to be transferred onto the service users’ plans. EVIDENCE: During the inspection the inspector had the opportunity to speak at length with service users, their relatives and visiting professionals. Whilst talking to the relative of one service user it was established that the home had arranged to visit her relative prior to admission and that information relevant to the service had been provided. The relative also confirmed that arrangements to visit the home had been made by the family and service user before admission was finalised and that the staff and environment had created the right first impression. Discussions with staff were less enlightening, in respect of pre-admission inspections, although several people recalled visiting the home prior to moving into the home. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 9 A review of the pre-admission assessment tools confirmed the existence of a documented pre-admission format, although its relationship to the care planning process is less clear. It is essential when generating a pre-admission assessment or ongoing assessment tool that it clearly links to the care planning process, so that relevant information can be transferred to the care plan accordingly and can be reviewed and updated regularly. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7. The home’s general risk assessment tools should be reviewed and made more user friendly and appropriate to the service. EVIDENCE: During the 21st July 2005 inspection the range of risk assessments undertaken by the home was queried and a requirement made that the home improve this aspect of its care-planning process, the requirement being broken down into specific areas, pressure sore assessment, nutritional assessments, etc. At this visit the inspector noted that some progress in addressing this requirement had been made, as the home had obtained a series of documents aimed at the nursing profession, which they felt might be suitable for addressing the issues identified in the last report. However, as the home is not a nursing home and the staff are not qualified or trained in the use of such tools the management might be better to concentrate on the development of a more simplistic, yet informative risk assessment document, that would identify any potential problems and highlight the need for action, which in the case of health or medicalised Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 11 problems should prompt a call to the appropriate agencies/services, i.e. general practitioner, community nurse, etc. Risk assessments should also be used to gauge or rate any action that might potentially be harmful, the intention of assessing or rating the risk being that it enables us to take reasonable steps to manage the situation, low risks requiring (potentially) no response, whilst high risks may require the use of measures that limit the person’s liberty or right to self-determination, etc. The management must take steps to address the shortcomings of their risk assessment process, although as stated on several occasions they must keep this simple and straightforward. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. All of the core standards within this section were reviewed at the 21st July 2005 inspection and therefore not revisited during this inspection. EVIDENCE: None Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 13 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): None. All of the core standards within this section were reviewed at the 21st July 2005 inspection and therefore not revisited during this inspection. EVIDENCE: None Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 14 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): Standard 26. The management must take steps to ensure the kitchen is not used as an access to the laundry. EVIDENCE: Whilst sat in the lounge talking to some of the service users coming through for lunch the inspector noticed the hairdresser pass through the dining room, enter the kitchen and exit out via a rear door to the laundry. This would normally not be a concern, although whether the kitchen should be used as an exit and entry point to the home, especially during the final stages of a meal being prepared is for the manager to consider, however, as the hairdresser was carrying towels used whilst cutting people’s hair it was felt unnecessary and inadvisable to use the kitchen in this way. This was brought to the manager’s attention, who confirmed she had seen the hairdresser pass through and that this was not normally the practice of the home, the hairdresser should have left the towels for staff to collect later. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 15 It has been agreed that in future the manager will ensure staff provide the hairdresser with a laundry bag so she can dispose of any towels, etc. used directly into an appropriate receptacle. In conversation with the deputy manager it was established that contact had been made with the infection control advisors at the local trust following the last inspection and that information about the use of waste bags and soiled laundry, etc. had been sought. The home is now stocking red laundry bags for use with soiled or fouled laundry, or in the case of the hairdresser, laundry that might poses a contamination risk. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 16 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): Standards 27 & 28. Staff are deployed in sufficient numbers and have sufficient skills and knowledge to ensure the wellbeing of the residents. Staff training is sufficient to ensure appropriately skilled employees who are competent in their jobs care for service users. EVIDENCE: To date 7 of the home’s 14 staff possess a National Vocational Qualification (NVQ) at level 2 or above with a further 3 care staff in the process of completing their NVQ qualification. Currently this means that 50 of the staff team hold an NVQ qualification, which should rise to 64 in 2006 when the additional staff complete their courses. It was evident from talking to the service users that they appreciate the caring qualities of the staff, which could be attributed to their training and skills development, although the service users had little insight into the training completed by staff. It was also established that the staff are held in high regard by visitors to the home, with both the service users’ relatives discussing the caring nature of the staff and their ability to tell you about your relative without having to go off first and read up about them, and professional visitors praising the Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 17 communication skills of the staff and their willingness to work with and cooperate with treatment plans, etc. The latter comments also indicative of a well motivated and well trained staffing team. During the inspection the inspector met several core staff members who had worked at the home for some time, those staff met were both accommodating and happy to discuss their roles and responsibilities with the inspector and were quick to confirm the training events they had attended and the opportunities for accessing courses. Staff are deployed across three main shifts, mornings, afternoons and nights, with two care staff on each shift: A.M. P.M. Night. 08.00 hrs to 14.00 hrs two care staff on duty. 14.00 hrs to 20.00 hrs two care staff on duty. 20.00 hrs to 08.00 hrs two wakeful night staff on duty. In addition to the care staff the home also employs catering staff, domestic staff and one of the management team is supernumerary and attends to all administrative issues. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 18 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): Standards 31, 33, 35 & 38. The current manager does not possess the required or recommended qualifications, although steps to address this issue have been taken. The interests of the service users are safeguarded by the home’s quality auditing process. The home is not taking adequate steps to safeguards the monies of a service user. The management is not fulfilling their duties in respect of health and safety. EVIDENCE: At the previous inspection, 21st July 2005, the manager was advised of the need to obtain a management qualification at National Vocational qualification level 4 or equivalent, which is the minimum expected of managers within the social care field. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 19 The current manager, who is also the proprietor of the home, has decided that rather than study for a NVQ 4 in management herself she would rather promote the deputy manager and has in fact submitted an application form to the Commission on behalf of the deputy manager. In discussion with the deputy manager it was established that she has worked with the proprietor for a number of years and started as a care staff and worked her way up through the ranks. She is a confident and competent individual, whose knowledge of the business and the service users was good. The deputy has also studied and completed her NVQ level 4 in care and is completing the relevant management qualification in preparation for managing the home. The home operates a mixed Quality Auditing (QA) system that comprises both formal and informal processes for monitoring the service. The formal processes witnessed or established as being in use during the inspection included: • A client satisfaction survey, which seeks the views of service users, relatives and professional agencies has been located and is in the process of being circulated. Monthly reviews of the care plans. Annual reviews and updating of the home’s policies and procedures files. • • The home also has more informal processes: • • The maintaining of a file for letters and cards of compliment and thanks. Discussions with service users (unrecorded) regards the home and service provided, undertaken by the manager on a daily basis. Throughout the inspection the service users spoken to were very clear about the benefits of living at the home and how they enjoyed and appreciated life at Clarendon Care Home. People clearly felt part of the home and sufficiently involved in decision-making about the how the service affected them directly. In conversation with a service user’s relative it was established that the family felt part of the person’s care and that the home had developed a good rapport with the family and resident, easing communications and ensuring all parties are involved in the care planning process. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 20 It was ascertained that ideally the home would prefer not to become involved in the accounting or management of monies for service users (personal allowance) and instead would like to operate an invoicing option (tick), whereby the home purchases items for the client and then invoice the person responsible for the settling the invoice for the items purchased, as they do for the hairdressing currently. However, whilst this option is preferred the home is currently holding monies for one client, the person having an individualised account book and container for storage of any cash and/or receipts. Whilst reviewing the account it was noticed that none of the transactions undertaken on behalf of the resident were double signed, which has been a standard practice since a 1999 report produced by the Office of Fair Trading highlighted the problems of accounting for other people’s monies within residential establishments. The management is taking reasonable steps to address specific issues in relation to health and safety, i.e. there is a fire log in place that indicates the home is routinely carrying out checks on their alarm system, have acted out fire evacuations and fire drills and monitor emergency lighting, etc. The manager and her deputy have also taken steps to address the issue of infection control, identified at the last inspection, and have also arranged for staff training around the subject, as well as moving and handling and fire safety. However, despite the efforts made to manage these specific areas of health and safety the management team could produce no specific environmental risk assessments, which is a concern given the awkward layout of the home and the problem posed by steps to the dining room, etc. The proprietor has been advised of her responsibility as an employer to assess the environment for potential hazards and as previously with the individual assessments, gauge the risk and take action accordingly. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 22 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. 2. Standard OP3 OP7 Regulation Requirement Timescale for action 17/04/06 17/04/06 3 OP26 4. OP38 Regulation The home must generate an 14 assessment tool that will fit with their care-planning programme. Regulation The management team must 13 develop simple usable risk assessment tools, based on the principles of good risk assessment. Regulation The manager must take steps to 13 ensure people do not use the kitchen as a means of accessing the laundry. Regulation The manager must complete full 13 and detailed environmental risk assessments. 17/04/06 17/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP35 Good Practice Recommendations Staff should double signature all transactions undertaken on behalf of a service user. Clarendon Care Home DS0000039959.V279565.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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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