CARE HOMES FOR OLDER PEOPLE
Clarendon House Carrwood Road Bramhall Stockport Cheshire SK7 3LR Lead Inspector
Mrs Fiona Bryan Unannounced Inspection 20th November 2007 09:45 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 House DS0000008548.V351876.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 House DS0000008548.V351876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Clarendon House Address Carrwood Road Bramhall Stockport Cheshire SK7 3LR 0161-488 4107 F/P 0161 488 4107 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) Davenport Manor Nursing Home Limited Sally Ann Turner Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (32) of places Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: *up to 32 service users in the category of OP (Old age not falling within any other category); *up to 10 service users in the category of DE(E) (Dementia over 65 years old). 9th May 2006 Date of last inspection Brief Description of the Service: Clarendon House is a residential care home that is registered to provide accommodation for up to 32 older people, including ten residents who have a diagnosis of dementia. Clarendon House is one of two residential care homes owned by the Davenport Manor Nursing Group, the other being Davenport Manor residential care home. The registered providers are Kiran Patel and Mr Dilip Patel. The manager is Ms Sally Turner. Clarendon House is a large Tudor style residence, situated on Carrwood Road, Bramhall. The home is set back off the road with substantial gardens surrounding the property with access to Bramhall Park. There are no bus routes that run directly to the home. The nearest shops are situated on Bramhall Road or in Bramhall village, which is approximately a five-minute drive away from the home. The home has 20 single rooms, ten of which have en-suite facilities and six double rooms that have no en-suite facilities. All rooms have a washbasin. There are two lounges and two dining rooms. There is a passenger lift to assist residents to their bedrooms on the first floor. The home is suitable for wheelchair users. Rooms at Clarendon House can be contracted on a private basis or funded by the local authority. Fees range from £315 for a shared room funded by the local social services department, to £384 plus a £40 top fee. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Tuesday 20th November 2007. The manager was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people who live at the home, the manager and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A tour of the building was conducted and a selection of staff and care records was examined, including medication records, employment and training records and staff duty rotas. Before the inspection, comment cards were sent out to residents and relatives asking what they thought about the care at the home. Nine relatives and eight residents responded and their comments have been included in the report. We also sent the manager a form (AQAA) before the inspection for her to complete and tell us what she thought they did well and what they need to improve on. We felt that the manager had tried hard to be objective about how the home was performing and the information she supplied was, in the main, accurate. What the service does well:
Without exception, the residents spoken to said that the staff at the home were very kind and caring and looked after them well. Comments received from them and from the surveys sent to residents and relatives included “the staff are neat and efficient and always friendly”, “The residents are treated with respect and dignity. The staff are well mannered, kind and caring at all times I have visited”, “There is always a warm homely atmosphere between the residents and staff so everyone seems happy and well cared for”, “all the staff are very friendly” and “Staff are very polite and kind”. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 6 People were very positive about the contribution the manager was making to the home saying, “The home is well managed. Any concerns are dealt with quickly and efficiently”, “I feel the home is better managed now and Sally (the manager) is always helpful and polite” and “Sally is lovely, very understanding”. Residents and relatives also felt confident that any concerns they had would be listened to and dealt with properly. Residents liked the food provided by the home. One resident said, “There are lovely cooks and they do beautiful food” and a relative said, “the meals are freshly cooked and a credit to the cook” and another relative said, “(the home) provides good food which mum enjoys”. Residents said they discussed their care plans every month with their key worker, when they were weighed and had their blood pressure checked. They said that staff were prompt in asking their doctor to visit if they were unwell and relatives said the staff were good at keeping them informed about any problems concerning the residents. Staff are encouraged to undertake NVQ training and 55 of the care staff have this qualification. The manager has tried hard to seek the views of residents and their representatives about what the home does well and what areas still need improvement. There was evidence that some changes were being made as a result of feedback from residents. The overall atmosphere of the home was relaxed and calm. Residents said the home was warm and homely and kept clean and tidy. A relative commented Clarendon House provides “a warm and caring environment” and another said, “the atmosphere is calm and comfortable. All the residents always look clean and smart”. One resident, when asked what the best thing about the home was, replied “the niceness of the carers, they are very, very sweet, lovely”. What has improved since the last inspection?
Since the last key inspection a shorter random inspection has also been undertaken at the home on 27th September 2006, to monitor the home’s progress since the last inspection in developing care plans and risk assessments relating to service users. Medication records were also looked at to monitor whether variable dosages of medication are recorded correctly. At that time, requirements made at the previous key inspection on 9th May 2006 had been complied with. A short report about the random inspection is available on request.
Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 7 Medicine procedures at this inspection were still satisfactory, which showed that improvements made had been sustained. Since the last inspection, most staff have now completed training in safeguarding adults from abuse and further training had been organised for December 2007 for the remaining staff. One incident at the home had been managed well, showing that staff were confident in reporting concerns and the manager was proactive in informing all the relevant agencies and ensuring the safety of the residents 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. The summary of this inspection report can be made available in other formats on request. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 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 House DS0000008548.V351876.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed assessments are undertaken before people come into to the home so they can feel confident that their needs can be met. EVIDENCE: A statement of purpose and a service user guide are made available to prospective residents/visitors to the home. These contain all the information required to ensure that people can make an informed decision about whether they want to live at the home. One resident said she had been to look at three homes before deciding to live at Clarendon House and had immediately liked the atmosphere when she came to view the home. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 10 Three residents were case tracked. Copies of contracts between the home and the local authority, and also between the home and the individual resident, were kept on file. The terms and conditions of residence detailed what services were covered by the fees and what additional costs the resident might expect. Assessments had been undertaken for all three residents case tracked. On the day of the site visit a new resident was being admitted to the home. The manager was in the process of transferring all their assessment details into the resident’s care file and had started to write care plans to address their needs. It was reported that letters are now sent to residents and their representatives to confirm that they have been assessed and the home can meet their needs, prior to their admission. It was noted that staff took time to reassure the new resident and tried to ensure they were settled and comfortable in their new surroundings. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The health and personal care residents receive is generally based on their individual needs; care plans need further work to reflect this. EVIDENCE: Three residents were case tracked. Each resident had a file that contained their assessment details and risk assessments, such as moving and handling, Waterlow and falls risk assessments, all of which had been reviewed monthly. Records also showed that each resident’s care plans had been reviewed monthly with their key worker and that the resident had been involved with the review and was happy with the care being planned and provided to them. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 12 On a daily basis, carers used another file that contained a copy of each resident’s initial assessment information, together with their care plans and daily records. Care plans for each resident tended to be fairly basic and did not always inform staff about how they were to monitor the resident’s progress. For example, the nutritional care plan for one resident said that they should be prompted at mealtimes and staff should “document if concerned about the amount eaten” – there was no clear indication as to what action would be taken if concerns were identified or how the resident’s nutritional status could be systematically monitored, i.e., how often the resident should be weighed, although all residents were actually weighed once a month as a matter of routine. Another resident needed a pressure-relieving mattress but there were no details about this in their care plan; staff need this information so they can check that the equipment is set correctly and working properly. Although in each resident’s separate file the key workers had recorded that the care plans had been discussed and reviewed and comments were available to reflect any changes to the resident’s needs, the actual care plans that the carers were using daily had not been updated, for example, one resident had started a diabetic diet but their care plan did not show this. One resident had lost weight and been referred to their GP, which had been identified during their monthly review with the key worker but no care plan had been developed to say how this would be addressed. If records are kept in different places to make it easier for staff to use, care must be taken that all the relevant documents are updated so there is no conflicting information. However, despite some inconsistencies in the record keeping, we were satisfied that the manager had identified where residents had developed additional care needs and people were being monitored carefully. Records showed that residents had seen opticians, GP’s, chiropodists and dentists. One resident was being seen by the dentist, at her request, on the day of the site visit. Residents said that if they were ill, staff were prompt in calling out their doctor and were happy with the care they received at the home. Staff were knowledgeable about residents’ care needs and were able to outline their preferences and abilities. Residents looked clean, tidy and well cared for, although the records of when people were bathed appeared to show that residents sometimes did not have a bath for as long as two weeks. The manager said that sometimes people refused to have a bath, although staff seemed to have recorded these occasions. Residents spoken to only talked about having one bath or shower a week at the most – it is recommended that residents’ preferred frequency of baths is discussed and checked with them at their monthly review. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 13 Residents said staff were kind and polite and respected their privacy. One resident who shared a room said this caused no problems at all in relation to her privacy and she was happy with the steps staff took to maintain her dignity. Examination of a small sample of medicine administration records showed that staff were following the correct procedures and no issues were identified in relation to the management of medicines within the home. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are able to make some choices about their lifestyle but further consultation is recommended to ensure that routines of the home do not impact on the flexibility of their preferences. EVIDENCE: An activities programme was displayed in the reception area of the home which showed that various activities, such as quizzes, bingo, skittles and reminiscence sessions, were planned on a weekly basis. However, on the day of the site visit armchair aerobics was advertised as being the activity for the afternoon but this did not take place – the manager said that the programme was more an idea of the type of activities arranged rather than an actual plan that was always adhered to. Staff kept a record of activities that had been offered to residents; these seemed mainly to be manicures, bingo, beauty therapy, films, quizzes, skittles and noughts and crosses.
Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 15 Several residents said they preferred to spend time in their own rooms, either reading or watching television. They were aware that some social events were organised but said these did not appeal to them. The manager said that most residents had been registered with Ring and Ride so that staff could take individuals out to the local shops and town centre. Some residents had been to the Staircase museum in Stockport, which they had enjoyed. Ministers from the nearby church visit regularly and some residents had attended the church recently for the harvest festival. Arrangements had been made to take the majority of residents to the pantomime at Christmas and two schools had been invited to send their choirs to sing carols for the residents. Several of the residents said they got up in the mornings “depending on the staff”, saying that staff were very busy and they fitted in with when was convenient. Residents did not seem unhappy with this, although one resident did say that occasionally they would like a longer lie-in and that after they had eaten breakfast in their room, they would lie down on the bed again for another doze. It did seem from talking to some residents that they tended to accept routines as the norm and did not think to ask for changes to meet their own needs. For example, one resident said they enjoyed quizzes and they had heard there was a quiz on a Monday afternoon but they could not attend, as Monday was their “bath day”. This was discussed with the manager who said that routines were flexible and residents were encouraged to arrange their day to suit themselves. It was suggested that discussions about people’s routines could be held with them as part of their care plan review each month with their key worker. Residents said that their visitors were made welcome at the home and one resident said she kept in regular contact with family by using her mobile phone. Residents, without exception, said the food provided at the home was very good. Comments included “The meals are very, very nice, very, very good”, “There are lovely cooks and they do beautiful food”, “the food is brilliant – wonderful food” and “the food really is quite good”. Residents said there was no choice of meal at lunchtime, but thought that if the meal was something they did not like, they would be offered an alternative. Residents said there was a small choice at teatime and breakfast was cereals and toast but they did not think a cooked breakfast was available. The day’s menu was displayed on a whiteboard in the reception area. Lunch on the day of the site visit was cottage pie, carrot, swede and cabbage, followed by pineapple cheesecake. Tea was bacon, hash browns and tomatoes or soup and bread and butter or sandwiches, followed by chocolate mousse.
Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 16 Lunch was served at about 12:30pm. Residents sat in two dining rooms. The atmosphere in both rooms was calm and pleasant. The meal looked and smelled appetising and residents said they enjoyed it. It was noted that one carer stood up to feed a resident and was positioned with her back to the only other resident sitting at the table – no attempt was made to make conversation with either resident. Mealtimes should be used to promote social interaction where possible and carers should ensure residents feel comfortable and unrushed when they are being assisted to eat. Many of the meals served to residents were served on quite small plates. The manager said this was because some residents did not have large appetites and only required small helpings. However, small plates reduced the presentation of the meals and some residents were seen trying to eat food that was falling off the side of their plates. One resident said he would have liked more but no-one was offered second helpings. All the meals were plated up in the kitchen and served by the carers. One resident asked for a small dessert but was told they were all the same size. Consideration could be given as to how to allow residents more choice and control in terms of portion size. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The complaints policy is provided in the service user guide and is also displayed in the reception area. People said that if they had concerns they would speak with the manager and they were confident that she would deal with any issues properly. Nine relatives and eight residents returned surveys we sent out before the inspection. All of them said they were aware of the complaint procedure. Staff were aware of the home’s complaints procedure. The complaints record showed that one minor complaint had been made to the manager since the last inspection. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 18 Two staff that were spoken to were aware of the procedure to follow if they suspected abuse. Stockport’s local authority procedures for safeguarding adults was available in the staff office and all staff had been required by the manager to read it and sign to confirm that they had done so. Most staff had attended training and training had been arranged for 17th December 2007 for the remaining staff who required it. Since the last inspection the manager has reported to the relevant agencies allegations that were made by staff at the home about another staff member. The staff member concerned was suspended and subsequently dismissed and a full investigation was undertaken. This person was then referred for inclusion on the POVA list to ensure that they are not able to work at any other care home. The action taken by the manager showed that she was aware of the procedures to follow to safeguard the residents in the home and the wider community and was open and transparent in informing the necessary agencies. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is generally well maintained and provides comfortable living accommodation for residents. EVIDENCE: A tour of the home was conducted. Standards of hygiene and cleanliness throughout the home were good. The home provided comfortable accommodation and was free from any unpleasant odours. A number of service users’ rooms were seen, which were furnished and equipped to a comfortable standard. Many had been personalised by the occupants, who said they liked their rooms and were satisfied with the laundry and cleaning arrangements. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 20 It was reported that a new maintenance person had been appointed fairly recently who divided his week between Clarendon House and it’s sister home. The manager said she tried to ensure rooms were decorated as they became vacant. Since the last inspection a new carpet had been laid in the basement and handrails had been installed. A recent food hygiene inspection had been undertaken and the actions requested from this were being dealt with. The home is in need of some redecoration and upgrading. Relatives who returned our survey before the inspection and also relatives who have responded to a survey conducted by the manager, did comment that the home was in need of some interior refurbishment; one relative commented that the communal rooms were “dull”. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was sufficiently staffed and recruitment procedures ensured that service users were protected. EVIDENCE: In the AQAA, the manager reported that staffing levels had been increased in the afternoons and evenings to meet the demands of the service. Staff said that there were usually enough staff on duty and that the manager would “step in” and help the carers if someone was off at short notice. On the day of the site visit 28 people were in residence at the home. Six carers were on duty until 5pm and then five carers were on duty until 8pm, after which there were four carers on duty until 10pm and then two carers on duty at night with an extra carer sleeping-in for back-up cover if it was required. Examination of the staff duty rota confirmed that these staffing levels were the norm. The manager said her hours were supernumerary but she did spend some time working with the carers and delivering personal care to residents in order to gain firsthand knowledge about the condition of residents and any difficulties their care presented to staff.
Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 22 The personnel files for two staff members were examined. Both contained evidence that all the necessary checks had been made before they started work at the home. The manager reported in the AQAA that 55 of care staff have successfully completed NVQ training and a further six staff are undertaking the training at the present time. Staff said they had received training in various topics, such as first aid, safeguarding adults, dementia awareness, infection control, care of colostomies and fire safety. Moving and handling training had been arranged for the following day. New staff receive induction training that is specific to the home but the manager said she was also intending to enrol them on induction sessions that met Skills for Care specifications as they became available. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Systems are in place to create an open and inclusive atmosphere, which provides a positive home for people to live in. EVIDENCE: Since the last key inspection a manager has been appointed who has registered with the CSCI. The manager has an NVQ level 4 and has successfully completed the Registered Manager’s Award. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 24 Staff, residents and relatives were very positive about the manager and felt the home had improved since she took over. Residents said that they saw her around and about the home a lot and that she was approachable and understanding. Staff said she was “fair” and “a good manager”. The manager said she kept an open door policy and tried to make time to talk to residents on a daily basis. Residents and other stakeholders’ surveys had been carried out in August 2007 and the results and comments received had been analysed to identify strengths in the home and areas for improvement. Of 23 responses from residents, nine had said the overall care was excellent and 14 said it was very good. Sixteen responses had been received from other stakeholders and all commented on the welcoming atmosphere in the home and the friendliness of staff. Some comments that had been made in the survey carried out in 2006 were repeated in this year’s survey in respect of the décor of the home and the wish of people for some redecoration. Some people had made suggestions about activities they would like to see at the home. The owner should consider trying to address some of these comments and involve the residents in choosing colour schemes, etc., for some refurbishment. Staff reported that the owners regularly visited the home and that they could speak with them if they had any matters they wished to discuss. The manager said she read residents’ care files each week and signed them to confirm she had done so. A record of weights and BP’s, etc., is kept and she also checked these monthly. This system seemed to work well as appropriate interventions had been initiated where there were changes to residents’ conditions. Residents’ meetings are not held at the home but the manager said she often chatted with residents informally. Procedures for the management of residents’ money were satisfactory. Staff said there was enough equipment within the home to enable them to carry out their jobs safely and staff were seen to be working using safe working practices. Regular checks had been made of the premises and equipment to ensure that everything was in good working order and well maintained. Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations Individual care plans should be added to and updated during the key workers’ monthly review with the residents, so they contain all the information needed for staff to work from. Residents should be offered regular baths at a frequency of their choice. Residents should be made aware of their freedom to adapt the home’s routines to suit themselves and should be encouraged to maintain their autonomy. Consideration should be given to offering a cooked breakfast to residents at least twice a week and the manager should also consider how to adapt the current arrangements for serving food, to allow the residents more choice in their portion sizes and improve the presentation of meals. Consideration should be given to refurbishing the communal rooms. 2 3 4 OP8 OP14 OP15 5 OP19 Clarendon House DS0000008548.V351876.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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
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