CARE HOMES FOR OLDER PEOPLE
Clarendon Hall Care Home 19 Church Avenue Humberston Grimsby North East Lincs DN36 4DA Lead Inspector
Theresa Bryson Unannounced Inspection 2nd February 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.V281365.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 Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 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 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) Southern Cross Healthcare Services Limited Position Vacant 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.V281365.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th August 2005 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 now owned by the Southern Cross group of homes. The accommodation is on 2 floors and accessed by a 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 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. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in February 2006. Records were seen to make sure staff are checked and that they are safe to work with the people who live in the home and are trained to do their jobs. Paperwork was seen to ensure that the home was safe to live and work in and this was being monitored by the home. 4 staff were spoken to in depth and 3 more had brief conversations with the manager, 6 people who live in the home were spoken to and the acting manager. What the service does well: What has improved since the last inspection? Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 6 The care plan documentation has improved, assisted by new Company polices. The staff are now keeping the records up to date and writing them in a legible and clear manner, so the actual delivery of care for each person can be evidenced. The Administrator is now keeping a list of those permemant people who live in the home to be on the local electoral role, so they can vote and take a apart in local community activities. The Acting Manager is ensuring that the correct numbers of staff are on duty at all times to ensure that the needs of the people who live in the home can be met. The home has ensured that all staff files are up to date and adhered to the Regulations to ensure all checks have been made so they are safe to work with the people who live there. The quality assurance programme is being adhered to, to ensure that audits are completed on all aspects of running the home and the people who live there, work there and other stakeholders are surveyed to ensure the home is offering the right service at all times. What they could do better:
The manager must ensure that staff have received training in specific topics that current people who live in the home have and this will enable them to deliver the care with the latest knowledge base. This must include training in the protection of vulnerable adults so staff can identify any risks and know how to report events, so people who live there can be in a safe environment. The Company must ensure that a maintenance and renewal plan is in place to ensure the building is well maintained and a pleasant environment in which to live. All staff must ensure they adhered to fire precautions in the home to ensure the home is hazard free in the event of a fire. Advice must be sought for door closure mechanism for individual service users doors to ensure they adhere to the fire regulations. The staff must continue to work toward achieving their NVQ level 2 awards to enable them to develop the skills to look after the people who live there. The manager must ensure that all staff have received supervision and this is
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 7 recorded. This will identify any staff who require extra assistance or training to do their job effectively. The manager needs to progress with her Registered Manager’s Award to help her develop skills to effectively run the home. The manager must ensure that the comfort fund running for the people who live in the home is administered correctly and only staff employed currently in the home are signatories to the bank account. 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.V281365.R01.S.doc Version 5.1 Page 8 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.V281365.R01.S.doc Version 5.1 Page 9 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,,4 and 5. The Company provides a comprehensive document to enable prospective service users to make informed choice before entering the home. Each person is encouraged to maintain their independence as much as their individual conditions will allow. There was not sufficient evidence to show staff had updated their skills in specific topics to enable them to care effectively for service users, with the latest information. EVIDENCE: The CSCI has agreed a corporate statement of purpose and service users guide for the Company. The local area will then add sections pertinent to their registration and local community. This was seen to be a comprehensive document and details in depth the services available to prospective service users to enable them to make informed choice about the home. The home encourages people to look around prior to admission and no charge
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 10 is made for a one-day stay. The manager will try and accommodate the wishes of the prospective service user in the type of room on offer and how this is to be laid out prior to admission. This will enable them to feel more comfortable in before admission. There was insufficient evidence to support that staff had received service specific training in the home, but some is planned for this forth-coming year. The manager has purchased a series of videos to cover most conditions seen in the home, to assist staff until such time as other training can be put in place. Attendance at these sessions needs to be evidence and open for inspection. Training in specific topics will enable staff to keep up to date with the latest research to enable them to effectively care for each person. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 11 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 and 10. The company has a comprehensive tool to enable staff to document accurately the care delivered to service users, which appeared to be correct at the time of the visit. Staff were seen to assist service users with dignity and respect. EVIDENCE: 3 care plans were checked in depth. Since the last inspection the company has issued new documentation, which if completed correctly enables staff to accurately document the care delivered and for this to be audited by company representatives and the CSCI. Of the care plans seen the record keeping appeared accurate and included documentation to enable the inspector to see how care was traced through auditing tools. Such as accident recording, traffic light system for tissue viability and weekly progress sheets for care delivered. Staff spoken to stated that they found the new documentation useful and easier to write. They also appeared to appreciate the auditing tools used to
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 12 keep them on track when using the records. Staff were seen assisting service users in a variety of tasks through out the day, in a sympathetic and dignified manner. Service users spoken to stated they found all staff kind and always ready to assist their every need. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 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 and 14. A varied programme of activities was provided to ensure that service users social, religious and recreational needs are met. EVIDENCE: The inspector spoke to the Activities Organiser at length about her role in the home and what she provides for each person. The records kept showed a number of activities available as group activities and also as one to one sessions. Each person had a record of when they partook in an activity, an assessment of their participation and what may need changing next time. There was also a separate record of activities, which was coded, which all staff could complete. The key workers complete the social needs assessment in the care plans and pass on this information to the activities Organiser. Activities included; - entertainers slide shows, games, quizzes, bingo, beetle drives. Visits had also been made by Pat-A-Dog, Time Care reminiscence group, a local Church and local Schools, Brownies and a variety of singers. The home also produces a newsletter, which is given to each service user and is also on display on a variety of notice boards around the home. Scrapbooks
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 14 and photos were also on display of a variety of previous activities. When a service user has died the Activities Organiser offers photos of the loved one to family for their personal albums, with permission of other service users if it is group activity. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 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): 17 and 18. Records were in place to ensure service users can exercise their legal and civic rights. There was no robust training system in place to ensure staff can identify service users at risk from abuse. EVIDENCE: Policies were in place to enable staff to ensure service users can exercise their legal and civic rights. The Administrator stated she keeps a list of permanent service users who need to be on the local electoral role. At the last election most choice to vote by post. The procedures for staff to follow should the need arise that an incident of abuse has taken place, were now in the policy manual. The majority of staff still have to complete some form of training in protection of vulnerable adults, and failure to so could put service users at risk from a lack of knowledge about this topic. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 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. The Company still has to produce a maintenance and renewal plan to show that it is maintaining the building to a satisfactory standard. The home was clean and tidy and checks had been made to ensure the equipment was safe to use. Fire safety precautions had been breached and the inspector asked the local fire officer to attend and check the risk factor to ensure it was safe for service users. EVIDENCE: The handyman accompanied the inspector on the tour of the home where all communal areas were seen, toilets, bathrooms and some service users one rooms. The home was clean and tidy and some individual rooms had been redecorated. It was stated by the handyman and the manager that the
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 17 Company have indicated that the home is top of the list for refurbishment. Some areas were looking very tired and could not be achieved in the normal maintenance week of work. Some minor work such as grab rails being loose and lights not working were identified to the handyman during the tour and were addressed before the inspector left the building. The Company must still produce a maintenance and renewal plan to ensure the building is being adequately maintained and safe to live and work in. It was necessary for the inspector to call the local fire officer to ask him to visit the home to give them some advice on door closure systems. Many individual room doors were wedged open with a variety of objects, which is in breach of fire regulations and could make the building unsafe in the event of a fire. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 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 recruitment and keeping of personal files showed a robust system now in place to ensure staff employed were safe to work with service users. Some training had taken place, but a training programme and some service specific training still needed to be in place to ensure staff are trained adequately to do their jobs. EVIDENCE: The rota system for care staff had improved and showed sufficient staff on duty at any time to meet the needs of service users. There were 2 part time care staff vacancies and a day a week for a cook still to be filled, other staff and agency staff had been employed to ensure the numbers of staff on duty remained the same. Some staff stated the busiest time was mornings and was also very busy for the trained nurses. The manager was aware of the situation and was keeping a close record of dependencies of service users to ensure the correct numbers of staff were on duty at all times, to meet service users needs. The numbers of staff enrolled on an NVQ level 2 courses had improved and the home was a third of the way to achieving the 50 target. The manager has purchased some training videos for staff to see whilst other
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 19 training is being set up. These cover a variety of topics and will assist staff to be trained to do their job correctly. More assistance from the regional trainer needs to be in place to ensure all aspects of care are covered and all mandatory training has been completed by all staff, with a training matrix in place. The staff personal files have now been audited and 3 were tracked in depth at the time of the visit. A new checklist was in place to ensure that all items listed in Schedules 2 and 4 of the Regulations had been obtained and staff had been checked to ensure they were safe to work with service users. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 20 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): 31,33,35 and 36. The Company has robust systems in place to ensure that the quality assurance standards are being met by the home and the home is checked to ensure it is safe for people to live and work in. A more robust system needs to be in place to ensure staff adequately supervised to complete their jobs. EVIDENCE: The Acting Manager is still to be vetted by the CSCI, as she is new to post. She has also just registered for her Registered Manager’s Award. This will give her an insight to her role and give her skills to cope with different situations within the home. The Company has a robust system in place for measuring its quality assurance
Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 21 audits and all documentation appeared to be up to date. All Regulation 26 site visits sheets and Regulation 37 notices arrive in the local CSCI office in good time and are very detailed in the information given. This enables the inspector to keep a track of the situations in the home at any given time. 4 service users personal allowance accounts were tracked in depth and found to be correct. Computer records are kept and showed appropriate entries on each account. Receipts were also seen. There is limited access to the records, which were kept in a safe place. The manager and administrator must ensure that the bank account held for the residents fund has more than one signatory and only current staff to sign and administer the account. This is to ensure all entries are correct and the money collected is being handled in a safe manner. The manager had commenced one system of supervision with staff, but due to other pressures in the home is now having to revise this system. There were insufficient records available to show that staff had been adequately supervised. This could put service users at risk from staff not being monitored correctly in their work and putting service users at risk. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 22 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 X 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 2 2 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 1 X X Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 23 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 OP4 Regulation 18.1c.i. Requirement The registered person must ensure that all service specific training is up to date and open for inspection. (Previous time scale of 30/04/05 and 30/12/05 not met). The registered person must ensure all staff have received training in the protection of vulnerable adults. (Previous time scale of 30/12/05 not met). The registered person must ensure that a maintenance plan is in place for the building. (Previous time scale of 30/12/05 not met). The registered person must ensure that all fire precautions in the home are adhered to by all staff. The registered person must ensure that all training records are up to date and a training plan in place to cover mandatory and service specific training. (Previous time scale of 30/12/05 not met).
DS0000002779.V281365.R01.S.doc Timescale for action 30/03/06 2. OP18 13.6. 30/03/06 3. OP19 23.2b. 30/03/06 4. OP19 23.4.a. 03/03/06 5. OP30 18.1.c.i. 30/03/06 Clarendon Hall Care Home Version 5.1 Page 24 6. OP36 18.2. 7. OP35 25.1. The registered person must implement the supervision programme to all staff. (Previous time scale of 30/02/05 and 12/09/05 not met). The registered person must ensure that the service users comfort fund is correctly administered. 03/03/06 30/03/06 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. Refer to Standard OP28 OP31 Good Practice Recommendations The manager is aware of the target date to ensure 50 of staff have completed their NVQ level 2 by 2005. The manager, who is a nurse, is aware of the target date for completing her NVQ level 4 in management in 2005. Clarendon Hall Care Home DS0000002779.V281365.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor 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
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