Inspection on 18/05/06 for Clarendon Hall Care Home

This inspection was carried out on 18th May 2006.

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

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

Other inspections for this house

Clarendon Hall Care Home 22/05/08

Clarendon Hall Care Home 05/06/07

Clarendon Hall Care Home 02/02/06

Clarendon Hall Care Home 08/08/05

Clarendon Hall Care Home 28/10/04

Clarendon Hall Care Home 12/05/04

Clarendon Hall Care Home 15/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Clarendon Hall Care Home 19 Church Avenue Humberston Grimsby North East Lincs DN36 4DA Lead Inspector Stephen Robertshaw Unannounced Inspection 18th May 2006 09:30 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 Hall Care Home DS0000002779.V295201.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 Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarendon Hall Care Home Address 19 Church Avenue Humberston Grimsby North East Lincs DN36 4DA 01472 210249 01472 210365 clarendonhall@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Limited 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) Muriel Broadhurst Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (46), Physical disability of places over 65 years of age (46) Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Clarendon Hall is a 52-bedded establishment for older people and physically disabled, both under and over 65 years of age. The home is purpose built and is owned by the Southern Cross group of homes. The accommodation is provided over 2 floors and is accessed by a passenger lift and various settings of stairs. There are some en-suite rooms and also a number of bathrooms and toilets, all within easy access to communal areas. There are a variety of sitting rooms and several dining areas, which are also used by the activities person. All garden areas are accessible for wheelchair users. The management team split the home into a unit for very ill service users and those who are more able, but each person can have access to the entire home, if they should so wish. The care staff and team are supported by a number of ancillary staff at the home and also a regional and head office team supplied by the parent company. The latter management staff make frequent visits to the home and are accessible by telephone and e-mail. The home also has access, and uses a number of health care professionals in the locality including the health and social care co-ordinators, district nursing team, tissue viability nurses and continence advisors. The fees for the home are as follows; Residential care £329-£425 Nursing care £372-£560. A top up fee additional to the contract price of up to £20 to individual service users is implemented by the home. This is only made to service users funded through their local authority and agreed through a third party agreement. The home has an additional fee on top of the contracted fee that is between £5 and £15 for the service users. This is used for activities at the home and in the community. There are additional costs to the service users for the services of a hairdresser and chiropodist. The inspection reports are made available to the service users on the homes notice board. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on the 18th May 2006. Two inspectors were both on the site for approximately seven and a half hours. The service users were generally very happy with the care that they received at the home. The inspectors gathered evidence for this report through discussions with service users, contact with their families and friends, direct and indirect observation, observation of written information in the home and interviews with the staff and management of the home. The inspectors spoke individually to ten service users and five visitors to the home. Three staff were spoken to individually and a group of six staff were spoken to together. What the service does well: What has improved since the last inspection? The home is improving the way it gets the views of all of the people who live, work and visit the home to make sure that it is doing a good job or to decide how it can change things to make it better for everybody. This gives service users a voice that is listened to about their home. The staff are feeling more supported now that they are provided with individual; time to talk about how well they are doing, or if they need more training etc. Staff are now being given special training to help them look after Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 6 a variety of individual needs experienced by the service users. This helps service users to have more confidence that the home will be able to look after them as they get older and more frail because of heath problems. The home has not had a consistent manager in position for approximately five years. The current manager has recently successfully completed a fit person interview with the commission. Service users, staff, carers and outside professionals all said that having a consistent management system in the home had improved the services being made available and has also improved the morale of the service user and staff groups. Staff files showed that they have received appropriate safety vetting before they are allowed to have any contact with the service users. This means that vulnerable adults are protected from abusive situations at the home. 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. Clarendon Hall Care Home DS0000002779.V295201.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 Hall Care Home DS0000002779.V295201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 The quality outcomes in this area are adequate. This judgement has been made from evidence gained during and before the visit to the service. This means that the service users are provided with an opportunity to visit the home before they become resident there and their needs are fully assessed. EVIDENCE: The homes statement of purpose and service user guides recognise that the service users will be treated with dignity and respect regardless of their age, gender, sexuality, race and religious beliefs. The document also included an equal opportunity statement that also supported individual service users spiritual needs. The statement of purpose also included policies and procedures to uphold privacy, dignity, rights and choices, and fulfilment to ‘realise personal and full potential’ of the individual service users. These support the homes approaches to equality and diversity. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 9 Discussions with the service users confirmed how the staff promote these values. Service users are only admitted in to the home following a comprehensive assessment of their needs to make sure that the home has the ability to care for them appropriately. The individual care plans for service users had been developed from the identified needs in their original assessments. Nursing input to service users is determined through recognised nursing assessment tools according to the Department of Health guidance. The inspectors discussions with service users, visitors to the home, interviews with staff and direct observations supported the evidence that the home has the capacity to meet the assessed needs of the individual service users. Staff receive appropriate training to make sure that they can meet the needs of the service users. The home does not provide intermediate care to service users. Clarendon Hall Care Home DS0000002779.V295201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The quality outcomes in this area are adequate. This judgement has been made from evidence gathered both during and before the visit to this service. This is because service users with nursing care needs do not have all of these needs appropriately met at the home. EVIDENCE: The care plans observed by the inspector had mostly been evaluated on a regular basis to make sure that the services provided through the home were able to maintain the needs of the service users. However the care plans for service users with nursing needs were not all up to date. There were other difficulties identified with the individual care plans. The care plans are developed by the nursing staff and do not include any social aspects of the service users care, the daily diary records are also recorded in the same clinical way. This means that service users needs may not all be met appropriately at the home, as there is no identification of these needs. The care plans were supported by individual risk assessments where appropriate and the manager audits the care plans on a regular basis. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 11 Where appropriate the service users care files also included their care management assessments and care plans. There was evidence that the service users or their representatives are consulted in the development of the care plans. The care plans also clearly identified supporting service users with expressing their sexuality and individuality. There was also evidence that with the agreement of the service users family and friends are invited to the review of their care. In general the health care needs of the service users are met at the home. However there have been some concerns raised by the district nursing team in the lack treatment of pressure areas in the home and care staff not following the health care plans for the pressure areas. The concerns were in relation to one individual service user whose pressure area care plans had not been followed appropriately by the nursing staff at the home. As a result the pressure areas had deteriorated. Previously the home did not have a recognised policy and procedure for resuscitation this was found to be in position at this inspection. A service user identified with needs related to depression and anxiety did not have a care plan to support them with these needs. Service users that were identified as having behavioural problems did not have care plans to address these areas. Staff interviewed had not been given any guidance in how to meet the needs of service users with behaviour management problems. Privacy, dignity and respect were observed to be offered to the individual service users at all times during the course of the inspection. One of the service users said ‘ if I didn’t want a male carer to help me they would listen to me but he is so kind and nice that I like him to help me’. All of the care files observed by the inspectors included the service users last wishes in the event of their deaths. All contact with doctors and other healthcare professionals is recorded in the individual service users care files. Nutritional screening was included in all of the care plans observed by the inspectors. Optical prescriptions were also included in individual service users records. Service users and visitors spoken to by the inspector stated that when they use the call bell system the staff are very slow in responding to it. One service Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 12 user said that they had to wait for half an hour to go to the toilet and this had resulted in them having an accident that was embarrassing to them. The inspectors observed the prescribed medication being administered at the home. The staff involved adhered to all of the appropriate legislation and good practice guidelines to administer the medication. The controlled medication in the home was stored, recorded and administered appropriately. The individual medication records included photos of the service users to minimise any risk of the medication being given to the wrong service user. Additional medication for service users is hand scribed on to the MARS sheets. Quantities of the new medication are not signed in and the additions are not countersigned by another member of staff. Clarendon Hall Care Home DS0000002779.V295201.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality outcomes in this area are adequate. This judgement This means that the service users are provided with the opportunity to become involved in activities at the home and in the community. However the range of activities is limited at the home. EVIDENCE: The service users are provided with the opportunity to become involved in a activities at the home. The home has recently acquired the regular use of one of the company’s mini-buses. The home employs a really enthusiastic activity co-ordinator. She spends all of her time organising group and individual activities. She also speaks individually to service users to find out what their interests are but this is not recorded in their care plans and she is not included in the review of individual care plans. However the recording of when service users attend activities and how they responded to them was very limited. Service users and visitors stated that activities were limited in choice and that they were dependent on staff availability to support the service users. Staff stated that they often attend activities on their off duties to enable the activities to go ahead. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 14 Service user and visitors said to the inspectors that although the home provided activities it did not provide a stimulating environment for the service users. Care plans and discussions with staff and service user supported that contact is maintained with family and friends and the visitor’s book showed that there are a high number of visitors to the home on a daily basis. There is one younger service user living on a permanent basis at the home and there is a lack of diversity to meet her individual needs as the home more generally caters for the needs of older people. Visitors stated to the inspectors that they are made welcome whenever they visit the home. Service users stated that they have choice in what they do at the home including what time to get up and retire to bed. Service users confirmed that they always have a choice at mealtimes and that the meals were always of a very good quality. However there was one complaint in relation to a service users diet. They identified that the home only uses thick sliced bread and they find this difficult to eat and swallow. Clarendon Hall Care Home DS0000002779.V295201.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The outcomes in this area are good. This judgement has been made from evidence gained both during and before the visit to this service. This means that vulnerable service users are protected at the home. EVIDENCE: The staff are being provided with protection of vulnerable adults training that is being led through the local authority training team. Staff interviewed by the inspector were aware of the different areas of potential abuse and were clear in the homes policies and procedures for reporting suspected abuse. The home has a complaints register. This is audited on a regular basis by the manager of the home. The complaints records include the content of the complaint that is made and the outcome of the complaint investigation. The service users and visitors to the home said that they would fell confident in making a complaint to the home and it being dealt with appropriately. Service users care files showed that they had been offered support to vote at the recent local and national elections. Where appropriate arrangements had been made by the home for postal votes. Other more able service users were supported to attend the local polling station. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26 The outcomes in this area are adequate. This judgement has been made from the evidence gathered both during and before the visit to this service. This means that the service users individual rooms are good and personalised to their own tastes and preferences making it feel more like home, however improvements to the general building are required. EVIDENCE: The inspector toured the premises and this included all communal areas, toilets, bathrooms and several service users rooms. No doors had been wedged open as identified at the last inspection of the home. The home was clean and tidy and most individual rooms had been redecorated. The home did not have a current maintenance and renewal plan. The Company Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 17 must still produce a maintenance and renewal plan to ensure the building is being adequately maintained and safe to live and work in. Generally the environment was in a good condition. One of the homes sluices had been put out of commission approximately twelve months ago due to health and safety reasons. The sluice has not been repaired or replaced and the home therefore has less sluicing facilities than previously. Staff stated that this can at times cause difficulties as the working sluice is down one end of the building and everything has to be carried to it there. This can have a detrimental effect on the environment service users live in causing temporary odours. The toilets and bathrooms were very clean and the home was free of any offensive odours. All of the toilets and bathrooms were in close proximity to the communal areas and the service users bedrooms. The home had an up to date fire risk assessment and a gas safety certificate that supported the safety of the environment. Service users were very positive in relation to their own rooms and the quality of the furniture and state of the decoration. It was obvious to the inspectors that the service users had been encouraged and supported to personalise their rooms to their own tastes and preferences. Appropriate aides and adaptations were observed in use throughout the home and the service records for this equipment showed that they are service and maintained on a regular basis. The heating and lighting was domestic in character and any hot surfaces had been protected to safeguard the service users. The laundry was well organised and the washing machines were programmable to disinfection and sluicing standards. Service users stated that it was only one rare occasion that they received the wrong clothes back from the laundry. The Inspector toured the kitchen area of the home and found it to be clean and well organised. The menus are organised corporately however the cook is hoping to develop an in house menu that is more appropriate to the needs of the service users. One of the fridge freezers was due to be repaired at the time of the inspection and the dishwasher was broken. The lighting in the kitchen is limited. It is provided by a strip light. The cook and the manager stated to the inspector that a quote had been obtained to replace the extractor fan in the kitchen. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The outcome in this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Service users are cared for by a staff group, which at times struggles to respond to residents needs and this could compromise their dignity. EVIDENCE: The staff rotas suggest that there are appropriate levels of staff working at the home at all times. However service users and outside professionals expressed some concerns that the nurses on duty had been reduced to one per shift for the whole home and all of the service users. Concerns were also raised in relation to the professional competencies of some of the nurses working at the home. The staff personnel files included appropriate references, job descriptions and CRB references. The application forms included equal opportunities monitoring and some of the staff were identified as being supported to work at the home with their own disabilities. Appropriate safety vetting is carried out for all of the staff before they have any contact with the service user group. Not all staff files included a copy of their contract with the company. However they all included terms and conditions of their employment. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 19 The supervision records in the home have improved and suggested that most staff are now receiving the recommended minimum of six formal recorded supervision periods per year. Where appropriate staff work permits were included in their files and were observed to be up to date and were accurately recorded. Discussions with the staff identified that the staff group is fragmented and there is poor communication between the care staff and the nurses. This should be addressed by the management to ensure that the service users needs are continuing to be met. Care staff stated that it is the nursing staff that develop the care plans however they are not fully aware of the service users needs as they do not ‘work the floor’. Staff records showed that a member of nursing staff returning to work after maternity leave was introduced directly on to the shift pattern without any support from existing staff and without full knowledge of the service users living at the home. This severely impacted on the workload of the care staff and the needs of the service users being met. Six care staff were working towards NVQ 2 in care and one member of staff has competed the award. Three staff have achieved NVQ 3 in care and an additional member of staff is working towards the same award. Six registered nurses, one enrolled nurse and one registered mental health nurse are employed at the home. The care staff receive appropriate mandatory training and specialist training in relation to the needs of the service users. The manager of the home has established a tracking system to ensure that the staff keep up to date with their training needs. Staff get paid to attend mandatory training if it is on their off duty. However if there is service specific training on their off duty and they attend it they are not paid for this attendance by the company. Staff stated to the inspector that they still attend these training session’s as they believe that is in their best interests and those of the service users and can improve the service users outcomes. The activity co-ordinator has completed specialist training with Age Concern to ensure that she can develop appropriate activities for individual service users and the service users group. Service users and visitors stated that the home would be more stimulating if there were more staff available and they ‘weren’t so busy’. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 20 The homes quality assurance and monitoring system is still in its infancy. Questionnaires were recently distributed however the returns had not been evaluated and no action/development plans had been implemented. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. This means that service users live in a home that has a stable management system. However this remains an area that requires further development at the home. EVIDENCE: A new manager has been appointed to the home and has been in position for approximately six months. She is a qualified nurse (RMN) and has a diploma in nursing. She is also undertaking the Registered Managers Award and has recently completed two units towards the qualification. This is her first management position. The manager recently successfully completed a ‘fit person’ interview with the Commission for social Care Inspection Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 22 The manager’s supervision has not yet been fully established within the company. However all of the managers in the group meet on a monthly basis for peer support and to discuss issues that may have arisen in their individual homes. A visitor stated to the inspector that the staff had been very supportive to their relative up to their death at the home but the manager did not offer any condolences following their death. They believed that this was not good practice. The majority of the staff, service users and visitors stated that the management approach to the home was open but some said that due to the history of ‘poor management’ at the home it was difficult to judge the openness and approachability of the manager as the manager had not been in the home long enough yet to get established and to instil confidence her abilities. The manager of the home is working ‘hard’ to progress the areas of the service that require further development and this is accepted as being ‘no small task’ for her. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 23 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 3 3 3 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 3 X 3 3 3 1 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 1 3 Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement The registered person must ensure that all service users assessed needs have appropriate care plans to address them. The registered person must ensure that care plans developed for service users by district nursing teams are followed by the nursing staff working at the home. The registered person must ensure that the broken sluice is repaired or is replaced. The registered person must ensure that a maintenance plan is in place for the building. (Previous time scale of 30/12/05 and 30/03/06 not met). Timescale for action 30/06/06 2. OP7 15 (1) 26/06/06 3 4. OP19 OP19 OP37 16 (j) 23.2b. 30/07/06 30/07/06 5 OP27 18 (1a) 24 (1a,b) 6 OP27 18 (1a) The registered person must 30/07/06 ensure the nursing staff working at the home are competent to meet the nursing needs of the service users. The registered person must 30/07/06 ensure that the whole team work as an integrated team and not as DS0000002779.V295201.R01.S.doc Version 5.2 Page 25 Clarendon Hall Care Home 7 OP31 18 (1cii) and (2) 8 OP33 24 (1) different sections of the workforce to effectively meet the needs of the service users. The responsible individual should make sure that the manager of the home receives the recommended minimum levels of recorded supervision. This should indicate their ability to manage the service. The registered person must make sure that the home has an effective quality assurance and monitoring system in position. 30/09/06 30/09/06 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 2 3 4 5 6 Refer to Standard OP9 OP12 OP15 OP15 OP28 OP31 Good Practice Recommendations The registered person should ensure that all medication quantities received by the home are listed and the amounts are countersigned. The registered person should make sure that services users activities are individually accurately recorded in the home. The registered person should consider increasing the electrical lighting in the kitchen area. The registered person should consider the use of only thick bread for toast and sandwiches at the home as this is not suitable for all of the service users. The registered person should ensure that a minimum of 50 of the care staff have completed their NVQ level 2. The registered person should ensure that the manager of the home completes her NVQ level 4 in management. Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clarendon Hall Care Home DS0000002779.V295201.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!