Inspection on 22/05/08 for Clarendon Hall Care Home

This inspection was carried out on 22nd May 2008.

CSCI found this care home to be providing an Good service.

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 Hall Care Home 05/06/07

Clarendon Hall Care Home 18/05/06

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

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Abbey The

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Hawkhills

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Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Clarendon Hall Care Home 19 Church Avenue Humberston Grimsby North East Lincs DN36 4DA Lead Inspector Rob Padwick Key Unannounced Inspection 22nd May 2008 11:55 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.V366659.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.V366659.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 Ltd 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) Michelle Pepworth 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.V366659.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th June 2007 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. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are on display in the entrance hall of the home. The latest inspection report for the home is available from the manager on request. Information given by the manager within the Pre-Inspection Questionnaire indicates the home charges fees from £361.00 to £522.00 per week plus the nursing band fees where applicable. Residents will pay additional costs for optional extras such as activities, hairdressing, private chiropody treatment, toiletries and newspapers/magazines and staff escort duties. Information on the specific charges for these is available from the manager. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home, which took place on 5th June 2007, together with information gained during a site visit to the home. As part of the inspection we send out an Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, which the registered person completed and returned to the Commission. This information helps us tell how well the home is meeting the regulations and national minimum standards, and what has been done to improve the service since the last inspection and what still needs to be done. The site visit took place on 22 May 2008 and lasted for 9 hours and the provider was not told in advance of this. We spoke to the manager of the service and various members of staff, as well number of people living in the home and their relatives. We looked round the home including the bedrooms and the shared areas, and inspected the records of people’s care, some staff files, the health and safety documents and other records maintained in the home. Other information used included feedback from questionnaires sent to relatives of people living in the home and professionals who know the service well. What the service does well: Clear information is provided to help people thinking about moving in to the home make an informed choice about it and their needs are assessed to ensure it can meet these appropriately. People living in the home are supported to maintain their involvement with friends and families and are provided with opportunities to take part in a variety of activities to ensure their well being is promoted. Staff have received training to ensure the concerns of people living in the home are taken seriously and they are safeguarded from abuse. The home provides a comfortable and welcoming environment that ensures the needs of people using the service are safely met. A friendly and generally well trained staff team are supported by a manager who has an open and inclusive approach to managing the home. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Hall Care Home DS0000002779.V366659.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.V366659.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): 1, 2, 3 and 6 People who use this service experience good outcomes in this area. Clear information is provided to help people make an informed choice about the home before deciding to move in and their needs are assessed to ensure it is able to meet them appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw evidence the provider had updated information about the service since the last time we visited the home, to help people thinking about moving into it make an informed choice about it. We saw evidence that contracts or terms and conditions had been issued to people using the service to give them information about what was included in the fee and what other services were available. The files of the three people we inspected contained assessments of their needs, carried out as part of their admission to the home to ensure it could meet these appropriately. The manager confirmed the service did not Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 9 admit people for intermediate care and information given to us in the provider’s self assessment, indicated plans were in place to ensure people accepted by the service would in future be supplied with a formal written offer of their placement which was in line with the homes policies and procedures. Clarendon Hall Care Home DS0000002779.V366659.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): 7, 8, 9, 10 and 11 People who use this service experience good outcomes in this area. Whilst the health and personal care needs of people living in the home were being met, their individual wishes and feelings about how these are delivered would be improved if staff consulted them more about these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated their health and personal care needs were being generally well met and information about a range of their needs had been developed into care plans, so staff could support them with these. The care plans were based on an “Assessment of Living” but rather complex and difficult to follow. Whilst people using the service told us they were aware of their care plans and saw evidence they had signed them to indicate their agreement with them wherever possible, a recommendation is made that these are simplified, to help people living in the home understand them better and Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 11 enable them to have more direct control and involvement over the care provided to ensure their wishes and needs about these are met. We saw evidence the health needs of people living in the home were being monitored and care plans were being regularly reviewed to reflect changing needs. Their was evidence of communication with outside professionals and staff told us that since the last time we visited “We have established valuable working relationships with outside agencies and this has benefited the service users greatly”. A District Nurse said “Nurses seem to contact specialist nurses for advice where their knowledge is incomplete” and confirmed prompt management action was now taken to address issues once known, however, their was some evidence this practice could still be improved. We saw evidence of appropriate management strategies to address known risks to people using the service, with various assessments of their needs. Their was some evidence people using the service needed to be consulted more fully and that an approach be adopted to enable them to take responsible risks in a safe manner. Some relatives told us “I feel my father is capable of bathing and showering and is upset that carers have to be in attendance” whilst another commented “My aunt took care of her own medication at home (and) was annoyed on occasions (She) was given tablets she didn’t want or not given pain killers when she would have taken them at home”. The service had policies and procedures to guide staff in the administration of medicines and their evidence that staff responsible for this had received training about this aspect of their work. A requirement made previously about storage of medication had been complied with appropriately and we received official notifications correctly concerning errors with these. We saw evidence the manager was regularly monitoring medication practices to ensure people living in the home were kept safe from harm and an inspection of medication records indicated these were being appropriately kept. Whilst we saw evidence people living in the home were able to maintain their privacy, the mixed comments received, indicated staff need to engage with them more fully and a recommendation is made about this to ensure their wishes and feelings are respected. We made a requirement following our last site visit concerning the terminal care needs of people living in the home. We saw evidence of staff training about this had been obtained since the last time we visited and the relatives we spoke to confirmed they were happy with the support and arrangements for this. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. People living in the home are supported to maintain involvement with friends and families and provided with opportunities to take part in a variety of social activities to ensure their general well being is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People using the service confirmed they could choose to take part in a variety of activities and we saw evidence of group singing and movement, hairdressing and personal manicure sessions taking place. The home’s activities organiser had recently won an award for her commitment to her work and we saw evidence of plans to involve those unable to take part in group activities, due to reasons of personal frailty or choice. One relative commented the service “Offers mental stimulation as well as physical care” whilst another stated “It is impossible to restore failing strength and memory, but staff have done their best and persuaded ---- to do activities I had failed to get her to do in the previous two years”. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 13 The atmosphere was warm and positive and relatives were observed visiting freely. One commented “Cheerfulness and patience (is) noticeably good….within the constraints of the job it would be hard to find a better set of carers”. Others however, indicated staffing arrangements sometimes needed improving “If staffing levels were increased there would be more time for staff to talk with residents and stimulate their interest”. A recommendation is made about this (See Staffing). We saw good evidence people living in the home were able to exercise personal choice and commenting on this a relative stated “mum is a very private person and allowed to stay in her room and have meals there if she asks”. We made requirements and recommendations previously about the nourishment of people living in the home and saw evidence these had been complied with appropriately. A new food trolley had been obtained to provide hot meals for people choosing to eat in their own rooms and we saw evidence in the case files of assessments about their nutrition. We observed people having their lunch, which was well presented in comfortable surroundings. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 14 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): 16 and 18 People who use this service experience good outcomes in this area. The concerns of people living in the home were being taken seriously and staff have received training to ensure they are safeguarded from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home confirmed their concerns were taken seriously and we saw evidence of a welcoming and positive approach to dealing with these. Whilst the Commission for Social Care Inspection had received no official complaints about the service since the last time we visited, the home’s complaints book contained evidence of actions taken to resolve the 13 complaints received by the manager. The home’s training records contained evidence of staff training about the protection of vulnerable adults and those staff we spoke to about this indicated appropriate action would follow should they have any concerns. At the time of our visit an allegation was being investigated under the Local Authorities duty to Safeguard Vulnerable Adults and we saw evidence the home had taken appropriate action following this. We inspected the records of money held on behalf of people living in the home and saw evidence these were being accurately held. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 15 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): 19, 20, 22, 24 and 26 People who use this service experience good outcomes in this area. The home provides a comfortable and welcoming environment that ensures the needs of people using the service are safely met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We made a number of requirements and recommendations about the environment following our last site visit and saw evidence of good progress in carrying these out. The décor and furnishings were of a good quality and saw evidence of a maintenance programme to upgrade the home further. Since our last visit to the service its exterior areas had been landscaped and most bedrooms redecorated to a high standard. We saw evidence of monthly audits carried out of the environment, together with action plans developed from these. Specialist equipment was available to maximise the independence of Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 16 people living in the home and we saw evidence of infection control measures to ensure it was kept clean and hygienic. At the time of this site visit a lift to the top floor was out of use, but we saw evidence of plans to repair this. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. Whilst the needs of people are generally well met by a staff team who are friendly and committed to their work, some further adjustments to the management of them would help them to do their jobs better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home told us their needs were generally well met and relatives commented favourably on the commitment and friendliness of staff. Whilst we saw evidence of a well-developed corporate staff training and development programme, we received comments that indicated improved arrangements could be made to enable better outcomes for people using the service. The home had recently experienced a number changes as a result of staff sickness and whilst the manager was monitoring this situation carefully, a recommendation is made that staffing levels are evaluated and reviewed to ensure they reflect the changing needs of the service. Appropriate policies and procedures were in place to ensure staff are safely recruited and we saw evidence of these being followed. The file of a recently recruited member of staff contained evidence they had started to work before a full Criminal Records Bureau check had been received for them however, and Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 18 the manager was reminded this practice should only be allowed in exceptional circumstances. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 19 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): 33, 33, 35 and 38 People who use this service experience good outcomes in this area. A qualified manager was being supported by appropriate management and administration systems to ensure the welfare of people living in the home is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since we last visited the home, the manager has registered with CSCI and obtained her Registered Managers Award qualification. We saw evidence she was a good listener and staff commented about her open and positive approach. Staff told us “I feel Clarendon has improved greatly over the last year…the manager is very approachable and fair and working to improve Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 20 services” whilst a relative said, “This is the best home I have seen or enquired about. Friends have also commented on the welcome they get”. We saw evidence that staff were generally well supported and the minutes of meetings and information contained in their files, confirmed a good sense of direction was communicated to them. We made a previous requirement that quality assurance systems were developed to enable the service to monitor its aims and objectives and saw evidence of meetings and surveys issued to people living in the home to ensure they are consulted about it. On the day of this site visit, a member of staff from the Parent Company was checking the homes records and we saw evidence that an operations manager also visited regularly. A deputy manager had recently been appointed to help the manager with the running the home and were told she was due to start a course for this. The records of money held on behalf of people living in the home were accurately maintained and we saw evidence of various regular checks to ensure their health, safety and welfare was promoted and protected. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 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 3 X 3 X 3 X 3 STAFFING Standard No Score 27 2 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 Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7OP7 Good Practice Recommendations The registered person should ensure care plans belonging to people using the service are developed in a format that can enable them to have a better understanding of them and enable them to have more direct control and involvement over the care provided and ensure it is in accordance with their wishes and needs. The registered manager should ensure that staff continue to liaise with outside professional to ensure the health needs of people living in the home are met. The registered person should ensure training is provided to ensure staff engage more fully with people using the service in order their wishes and feeling are respected. The registered manager should review and evaluate the staffing levels in the home to ensure these reflect the changing needs of the service. The registered person should ensure that a full CRB check is received for all new staff before they are allowed to start DS0000002779.V366659.R01.S.doc Version 5.2 Page 23 2 3 4. 5. OP8OP8 OP10OP10 OP30OP30 OP27OP27 OP29OP29 Clarendon Hall Care Home work in order to safeguard people living in the home from potential harm. Clarendon Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hall Care Home DS0000002779.V366659.R01.S.doc Version 5.2 Page 25 - 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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