Inspection on 25/10/07 for Clarendon Care Home

This inspection was carried out on 25th October 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 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 29/03/07

Clarendon Care Home 02/03/06

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 25th October 2007 12:00 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 Clarendon Care Home DS0000039959.V347581.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. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 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 Silvia Paton 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.V347581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th March 2007 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 the garden has been replaced with a newly tarmac surface, which is level. 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. The fees charged for accommodation at the home are £395.64. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures the service against core National Minimum Standards. The information used to write this report was gained from the homes Annual Quality Assurance Assessment; a visit to the service and a review of comment cards received from service users, relatives, and health and social care professionals. Other information was gathered from the services history of events, previous inspection reports, direct conversations with staff, analysis of information supplied to and recorded by the link inspector. The fieldwork visit, was conducted over four and half hours, where in addition to the paperwork that required reviewing we met with service users and spent time discussing their experiences of residing at the home and exploring whether their needs were being meeting. What the service does well: What has improved since the last inspection? Record keeping has improved with the manager introducing a number of new administration systems, which are intended to improve the monitoring and delivery of the service to clients, including: staff training, staff supervision and quality auditing. The provider has arranged for the rear patio area to be replaced with a flat and level tarmac area, which it is hoped will make the external aspects of the property more accessible to residents. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 6 The provider has also had installed new chairlifts, which make climbing some of the homes stairs much easier for both residents and staff escorts. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed when choosing the home and have their needs assessed. EVIDENCE: The manager has an internal pre-admission assessment process, which is designed to link into the homes care planning system. Several service user plans reviewed during the fieldwork visit contained completed copies of both the home’s pre-admission assessment and professional assessments obtained from Care Managers and Discharging Hospital Wards. During the fieldwork visit the opportunity to discuss the admission of their next-of-kin with a visiting relative arose this person describing how they had, on their relatives behalf, visited several home’s within the Southsea area settling on The Clarendon, as it had the nicest, warmest and most welcoming atmosphere. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 9 Similar remarks or statements were included within the relative comment cards returned in the build-up to the fieldwork visit, one person adding: ‘before my mother moved in I undertook an inspection of the premises along with my uncle, who is one of my mums brothers’ and ‘my mother had visited her friends in The Clarendon Care Home frequently and chose it for herself’. Five resident surveys were also returned in the build-up to the visit, four of the five indicating that they had received a contract, as part of the admission process to the home and all five ticket ‘yes’ in response to the question: ‘did you receive enough information about this home before you moved in so you could decide if it was the right place for you’. The home does not provide an intermediate care facility, as described under Standard 6 above. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive should be based on their individual needs and wishes, which should be reflected through the care planning process. Medication management was not based on current best practice guidance and thus had the potential to place service users at risk. EVIDENCE: A review of the service users plans failed to demonstrate how the service user are involved in the process of developing their own care plans, with each plan examined containing little personal information about how the resident likes to be cared for and supported. The plans were felt to be practical and provided basic instructions or guidance to staff on how to care for a person but the individualised elements of the process were missing and worked only on a level were everyone was seen as being the same and requiring the same support. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 11 This finding contrasted hugely with observation of the care being delivered, which was definitely individually tailored, the staff clearly aware of each persons distinct character and personality traits. A good example was the involvement of a resident with staff in tidying and maintaining the courtyard. The client was observed sweeping and removing garden rubbish from the area, which in conversation with the staff is a regular occurrence and one that provides a sense of fulfilment for the client. It also helps the person to manage or relieve stress and tension associated with the early onset of her dementia, which can at times leads to aggressive outbursts, however, this level of information is not reflected through the care plans. The home’s risk assessment process could also do with a similar review, as it to considers people in a one-dimensional way, failing to reflect a persons’ individuality. Each client residing at the home undertakes different activities, which have the potential to cause them or others harm, be this walking down the stairs, using a stairlift, going out, showing agitation, etc, which should be assessed by the staff and where necessary an individualised plan of how to manage and reduce the potential for harm created. In addition to the individualised risk assessments the manager and provider have a responsibility to undertake environmental risk assessments, which are intended to identify potential risks within the home and to produce plans to reduce the impact on people working and residing at the home, i.e. the stairlift’s, stairs, electrical equipment, bathing facilities, access points to the home, etc. Health care provision is well managed within the home with the member’s of the Community Nursing Team, spoken with during the fieldwork visit, stating that people are well cared for, that the management and staff are quick to seek advice and guidance, that referrals to their service are swift and appropriate, that the care staff are knowledgeable about the needs of the residents and that they carryout specific treats as guided by the professional staff. Observations established that visiting professionals are supported when undertake their visits, care staff noticed escorting the professional to see the client and remain with them for the duration of the visit. In conversation with the provider it was ascertained that staff often remain with the resident to provide support or at the request of the professional. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 12 Visits were also noted to take place in private, with the resident either taken to their room as the health care professional arrives or they are already in their room as a result of their ill health. The home is not large enough nor the layout suitable to accommodate an independent lounge that could be used for the purpose of entertaining visitors and visiting professionals. In rooms were people share their accommodation screening is provided, however, consultations with health or social care professionals needs to be sensitively handled, especially if both occupants are in the room, as personal information is private. Staff are aware of their role in protecting people’s rights, the Annual Quality Assurance Assessment indicating that staff have access to appropriate policies and procedures and under and induction programme based on the ‘Skills for Care’ induction, which considers issues of privacy, dignity and people’s rights. Information taken from the service user surveys indicate that the residents feel they are appropriately supported when accessing health and social care services and the service users plans contain records of visits undertaken by health professionals and any advice or treatments prescribed. The service users plans also contain details of the immediate community based services that people are involved with, including General Practitioners, Care Managers, Community Nurses, etc. The homes approach to managing peoples’ medication requires attention, as during the fieldwork visit the staff were involved in dispensing medicines from their original packaging into dosset boxes. This action is not based on current good practice for two reasons firstly the medication was being dispensed more than twenty-four hours in advance, so any mistakes could be repeated across a number of dosages and secondly, staff were being accessed to secondary dispense medication which blurs both the issues of responsibility and accountability. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style and are supported to develop their social, educational, cultural and recreational activities to meet their individual needs and expectations. EVIDENCE: The service users indicated via both the surveys and during conversations that they are happy with the level of activities and entertainments arranged within the home, with a particular visiting musician popular with all of the people spoken with. Some people recalled recent outings, including a fish and chip outing and a visit to the New Forest and picture collages, on display within the main communal area of the home, provided a visual account of people’s involvement in various parties and celebrations. The Annual Quality Assurance Assessment establishes that the management are happy to arrange for local religious group to visit the home, one small group often requesting a visit from the local priest. People were noticed to be Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 14 involved in a number of self-directed activities including knitting, cleaning the courtyard (as discussed) and reading. Shortly after arriving at the home the opportunity arose to discuss community contacts and visiting arrangements with a relative who had arrived at the home to take his relative out. The relative was clear that the home’s visiting hours suited both himself and his next-of-kin and that he often popped into the home, as his relative was fairly new to the service and he liked to make sure she was settling. The home’s visiting arrangements are clearly advertised within the ‘statement of purpose’ document and from the feedback provided by residents and relatives it would appear that they were all provided with copies of these documents during the pre-admission process. A visitor’s book is accessible within the main hallway and people are encouraged to sign in and out of the home by staff for fire safety purposes. Meals, according to the provider, can be taken either in people’s own rooms or in the dining room, which is a bright and reasonably sized room to the rear of the home. During the fieldwork visit people were observed taking both diner and tea within the dining room, these occasions noted to be very informal and friendly occurrences with people chatting to each other and engaging the inspector in conversation and light banter. The meals served appeared appetising and well proportioned, with the teatime options including a variety of sandwiches and additional snack items, fruit, crisps, etc. The menu’s are produced on a rotational basis and are developed around the known likes and dislikes of the people residing at the home and include any preferences voiced during the service users meetings. Nutritional screening is not routinely undertaken on admission to the home, however, people’s normal eating habits and any specialised dietary needs are documented. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to voice their concerns and have access to an effective complaints procedure and are protected from abuse. EVIDENCE: The dataset establishes the existence of the home’s complaints and concerns procedure, which was last updated in December 2006. The dataset also contains partial information about the home’s complaints activity over the last twelve months: No of complaints: 0. No of complaints substantiated: 0. No of complaints partially substantiated: 0. Percentage of complaints responded to within 28 days: 0. No of complaints pending an outcome: 0. The indication, from the relatives and service users comment cards is that people are made fully aware of the home’s complaints process and will implemented it where necessary, although most comments suggest that people have no concerns to raise. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 16 People also mentioned that the home’s complaints process is on display within the main hallway and therefore is accessible to all service users and their visitors. Details of how to make complaints and the home’s process for addressing concerns and complaints is also contained within the ‘statement of purpose’ and ‘service users guide’, copies of which are provided to people as part of the pre-admission process. The Dataset also establish that policies for the protection of the service users are in place and have been reviewed: ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’ both updated in November 2006. Whilst the Annual Quality Assurance Assessment states that staff receive regular ‘protection of vulnerable adults’ training, a statement confirmed during the fieldwork visit when the training records of the staff were scrutinised. The practices of the home also appear to support rather than restrict people’s rights to self-determination, privacy, dignity and respect, the example used earlier of the client involved in tidying the courtyard a good benchmark of the efforts made not to impinge upon people’s rights to live active and fulfilling lives. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a comfortable environment, which promotes independent mobility and movement around the home. EVIDENCE: A tour of the premise was undertaken, which enabled the inspector to ascertain that the property is in a good state of repair, both internally and externally and that the decorative condition of the home is good. The provider was available to discuss her plans for the development and upkeep of the property, which included the redecoration of the main lounge and also the recent resurfacing of the rear courtyard. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 18 People were quick to express their satisfaction with the general environment of the home, as well as their individual bedrooms, which the majority of people have personalised. One very independent client is heavily involved in maintaining and cleaning her room and was quick to assert that her room was laid out, as she liked and that her environment felt homely and safe. Maintenance records and service reports are appropriately retained by the manager and are easily accessed if required. Information taken from the Dataset indicates that all major appliances and domestic services are regularly serviced and maintained. Feedback provided by service users and their relatives, via the surveys, indicate that people feel the home is clean and tidy throughout with comments like: ‘absolutely spotless and free from any unpleasant odours’. During the tour of the premise the provider explained that in rooms where the clients are known to experience issues of incontinence the carpets are regularly shampooed, a statement supported by a member of staff who discussed her routine for cleaning rooms and using the carpet cleaner. The arrangements made to support people with such problems and the regular cleaning of their bedrooms does appear to be effective, as no unpleasant odours were detected during fieldwork visit. The Annual Quality Assurance Assessment makes clear that all staff attend health and safety training, which includes infection control and the storage/use of ‘control of substances hazardous to health’ (COSHH), whilst the dataset indicates that staff have access to infection control and COSHH policies and procedures. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are trained, skilled and provided in sufficient numbers to support the people who use the service and to management with the smooth running of the service. EVIDENCE: The home’s ‘statement of purpose’ sets out for prospective and actual clients the home’s staffing arrangements. The Annual Quality Assurance Assessment indicates that the staff are informed of their duties a week in advance, although realistically this should be a month. Records indicate that a minimum of two staff is on duty at all times, day and night, with the manager and provider available in a supernumerary capacity most days. During the fieldwork visit the home’s staffing complement was noted to included: two care staff, the provider, domestic and catering staff, although the later positions are only available for part of the day. Staff were noted to be available to support clients with all aspects of their care, social activities, including the lady involved in tidying the courtyard and throughout mealtimes. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 20 Staff, as discussed, were also noted to be available to accompany health care professionals during their visits, which the professionals, during conversations, acknowledged was normal practice for the home. The manager has developed a system for monitoring and documenting the training completed by staff, which includes the copying of certificates that are placed on the staffs files and a matrix system where she can enter the date of the course attended and ensure mandatory training sessions are completed and updated. Throughout the Annual Quality Assurance Assessment and the dataset the manager makes reference to the training completed by staff, courses including health and safety training, complaints and protection and food hygiene with both 100 of the catering and care staff having complete this course. Feedback, provided by service users and their families, via the surveys and comments provided by professional sources, indicate that the staff are considered to be both appropriately skilled and experienced. However, during the fieldwork visit it was noted that despite have recently completed medications training, according to the provider and confirmed by staff, the service users medications were not being appropriately handled. It is important when accessing training to ensure that the person or the agency providing the training have both the skills and qualifications required to deliver the necessary course content. Information taken from the dataset and confirmed with the provider, indicates` that currently the home employs thirteen care staff. Six of the thirteen care staff has completed a National Vocational Qualification (NVQ) at level 2 or above and this gives the home a percentage of 46 of its care staff possessing an NVQ at level 2 or above. The dataset also indicates that a further four care staff are completing their NVQ level 2 and if they all pass and remain with the provider the home’s percentage rate could climb to 77 . The dataset also indicates that all of the people who worked in the home over the last twelve months had undergone satisfactory pre-employment checks. On reviewing the files of three newly recruited staff all of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 21 The files also contained completed application forms, health declarations, photographs of the employee, personal information and information used to support the CRB application process. The dataset and the Annual Quality Assurance Assessment also make clear that staff complete an induction, which is based on the ‘Skills for Care’ induction standards and that staff are expected to complete this within the first six weeks of commencing their employment. During the fieldwork visit a number of different staff were spoken with all felt that training opportunities were good, that the staff team was stable and that this helped ensure a good level of service, although newly recruited staff had settled in well. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: A review of our date basis established that the manager only completed the registration process, to become the registered manager, on the 08th May 2007. She is noted to poses the necessary skills, experience and qualifications and previously held the position of deputy manager at the Clarendon Residential Home. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 23 Information taken from the service users and relatives surveys indicate that the home is considered to be well run and managed and that staff are considered to be helpful and kind. The fieldwork visit established that the newly registered manager has introduced a range of monitoring systems to the home and improved the home’s filing system, thus ensuring it is possible, even in her absence, as on this visit, for people to locate all required and requested documentation. One of the areas worked on by the new manager has been the home’s involvement of service users and other key parties in the auditing of care and/or service provided. The manager now regularly produces surveys to both families and service users, which she has used to inform or as evidence of the home’s practice within the Annual Quality Assurance Assessment. It is unclear, what else happens with this information and whether or not the outcomes of the surveys are shared with staff or used to change practice, however, as the outcomes of residents’ meetings do influence the service delivered, changes to menus or improved activities, etc, it is probably safe to assume that any information gathered is used constructively. The manager maintains minutes of residents’ meetings and a schedule of forthcoming dates has been drafted. The staff are also being provided with the opportunity to attend more frequent staff meetings, which are also minuted and retained for information by the manager. The Annual Quality Assurance Assessment also indicates that staff are receiving both regular supervision and annual appraisals a statement supported by findings made during the fieldwork visit when supervision records were noted to be on the staffing files. It was established with the provider that the home does not become involved in the management of people’s personal finances and that people are either support by their families, representatives or independently manage their monies, lockable facilities are provided for the purpose of storing any monies held. Annual Quality Assurance Assessment and dataset information establishes that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. Health and safety training is being made available to staff, with the Annual Quality Assurance Assessment and training files providing evidence of the Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 24 courses attended by staff, including: health and safety, infection control and food hygiene. A tour of the premise identified no immediate health and safety issues, although individual and environmental risk assessments should consider both potential areas of harm and how these can be managed to reduce the risk to people. Generally the service users and their relatives are satisfied with the service being provided at the home and feel the balance between care and independence is being appropriately maintained. Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation Requirement Timescale for action 09/01/08 2. OP9 Regulation The manager must seek to 15 involve service users more in the care planning process and to reflect their individualism through this process. Regulation The manager must ensure the 13 practice of secondary dispensing and dispensing medication more than twenty-four hours in advance are stopped. 09/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clarendon Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Care Home DS0000039959.V347581.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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