Inspection on 13/03/06 for Clarendon Manor

This inspection was carried out on 13th March 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clarendon Manor 23/02/09

Clarendon Manor 16/03/07

Clarendon Manor 14/09/05

Clarendon Manor 14/09/04

Clarendon Manor 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Clarendon Manor 37 Golf Lane Whitnash Leamington Spa Warwickshire CV31 2PZ Lead Inspector Lesley Beadsworth Unannounced Inspection 13th March 2006 10:45 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 Manor DS0000004310.V287038.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 Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clarendon Manor Address 37 Golf Lane Whitnash Leamington Spa Warwickshire CV31 2PZ 01926 426758 01926 426758 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) Greentree Enterprises Ms Emma Clayton Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: Clarendon Manor provides residential care accommodation for 30 older people aged 65 years and over. It does not offer specialist services for dementia care or any other provision apart from its registration category. Clarendon Manor is on a quiet residential road in Whitnash, on the outskirts of Leamington Spa. Shops and a post office are accessible to any service user who was able to walk to these facilities, otherwise a bus route is nearby. The forecourt of the home has parking for cars. The home consists of a period house, which has been extended by joining it through a ground floor corridor to a more modern house next door. A further extension has added 4 bedrooms to the third floor of the house; these are accessible by use of a lift. The home has two passenger lifts and a stair lift. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place on 13th March 2006 between the hours of 10:45 and 17:15. During this time the inspector had the opportunity to meet with the residents, observe the interactions between staff and residents , tour the premises, spend time talking to residents in private and in groups and examine documents relating to residents, staff and the management of the home. The registered manager was present for the majority of the inspection and one of the partners of the organisation was also in the home during most of the inspection. What the service does well: Discussion with residents indicated that they are able to make choices in their daily lives saying that they were able to get up and go to bed when they wish, choose the meal they preferred and whether to join in activities or not. Residents said that they enjoyed the food, several of them enthusing about the high standard. One resident said that she was vegetarian and that she always had tasty meals. Another resident said that she always looked forward to the next meal. The home has a simple complaints procedure that gives the residents the confidence that their complaints will be listened to and action taken. The gardens were tidy and pleasant for the time of year and residents in the smaller lounge spoke of how they enjoy watching and feeding the squirrels and birds that inhabit the garden. The home provides sufficient numbers of staff to meet the needs of the residents. Residents were complimentary about staff with comments such as, “they are as good as gold”; “everyone is nice and tries to be helpful”; “we are so well treated”; “ I wish I could produce such lovely meals.” Staff were seen to treat residents with respect and interact well with them. There has been progress in training with staff having taken part in training related to Nutrition and Health, Health and Safety, Infection Control, Medication and Moving and Handling. Other mandatory training, that is fire, first aid and introduction to moving and handling, has been made available on DVD. Six staff are undertaking NVQ Level 2 in Care. Senior staff have also undertaken relevant training. The registered manager advised, and training records confirmed, that the majority of staff have undertaken all mandatory training. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 6 Surveys are distributed at frequent intervals in order to obtain feedback on the service for residents and their family and friends. These surveys cover a different area of the service on each occasion, for instance in January general questions were asked; in February the survey concentrated on activities. The organisation carries out an audit on the environment of the home and action appropriately. A GP visiting the home at the time of the inspection spoke with the inspector and made very positive comments about the standard of service at the home. He said that he was always confident that there would be a senior person in charge when he visited the home and that the times that he was asked to visit the home were always appropriate. What has improved since the last inspection? Since the last inspection there has been a little progress in staff undertaking training to meet specialist needs, staff having attended Health and Nutrition training and continence management training having been planned for the near future. There has though been further progress in training with, manual handling, Health and Safety, Infection Control, and six staff undertaking NVQ Level 2 in Care. The registered manager has also attended training related to Adult Protection. More specific details have been added to the care plans to assist staff in identifying specific needs, although some further work is being done by the organisation to improve the plans. A policy has been put in place regarding Home Remedies to enable the home to administer ‘over the counter’ medication safely and with the GP’s agreement. At he last inspection there was some concern about the way food was being served. The registered manager advised that more serving tongs had been purchased and notices have been put in place as reminders to staff. There has been a little progress in the production of Regulation 26 reports from the registered provider but these are still not being forwarded to the Commission at the required monthly intervals. At the last inspection it was noted that a resident was in a wheelchair without footrest. As accidental injury can occur with this practice the home was requested to ensure that all wheelchairs had footrests unless a risk assessment suggested otherwise. The registered manager advised that this was now the case and no wheelchairs were seen without footrests during this visit. A qualified physiotherapist who is also a partner of the organisation has made a full assessment of the home. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clarendon Manor DS0000004310.V287038.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 Manor DS0000004310.V287038.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): 3,4,5 The assessments carried out by senior staff prior to residents moving into the home ensures the home can meet their needs. Not all staff have the training required to give them the knowledge and skills to meet specialist needs of people living at the home. EVIDENCE: Pre-admission assessments contain all the specifications required to meet this standard and to ensure that residents’ needs are identified. These are not reviewed or revised but the narrative type care plans include on-going assessment. However the registered manager needs to be mindful that any change in circumstances and therefore change in need is not overlooked. Some staff have undertaken training in Health and Nutrition and training related to Continence Management is planned for the near future. There continues to be a need for further training that would provide staff with the knowledge and skills to meet specialist needs, for example Dementia Awareness, pressure area care/skin viability, sensory impairment or physical disabilities. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 10 As said at the previous inspection there needs to be more in depth training on these subjects than can be covered in the organisation’s general training. The registered manager advised that she visits prospective residents in their own home and to carry out the pre-admission assessment. They are then informed of the decision and undergo a four week trial period at the home before making a decision whether to stay or not. Clarendon Manor DS0000004310.V287038.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): 7,8,9 Some progress has taken place to provide sufficient detail to support staff in providing the required care to meet individual needs. A home Remedies policy is in place to safeguard residents and enable them to receive treatment for minor ailments. EVIDENCE: All residents in the home have a care plan derived from assessments carried out although these tend to be more related to assessment of need and the resident’s daily routine (daily living plan) than giving care staff the information required to meet the needs of the residents. In an attempt to address this the registered manager has added bullet pointed instructions to the narrative-type care plans to highlight specific care required by residents and to enable staff to focus on this without having to read through the whole narrative. The daily living plan is a useful tool but does not contain sufficient information in sufficient detail for staff to ensure that all areas of need are included and that revisions are made as circumstances change. In care plans viewed there were discrepancies between observations made during the inspection, and discussion with residents, and with the care plans. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 12 For example one resident was said in the care plan to use a frame or walking stick but was walking about the home throughout the day without any aids. A resident was observed to have a major problem with continence, later confirmed by staff, but there was no reference to this in the care plan, leaving staff without any guidelines of how to manage this serious concern. A care plan also failed to fully address risks that a resident wanted to take and why there risks were not permitted. The registered manager formulated this risk assessment during the inspection but more in depth attention and possibly a multi-disciplinary review needs to be considered to ensure that this is the only way the person’s welfare can be care for and that unnecessary restraint is not being used. The registered provider and registered manager advised that the organisation was currently auditing care plans used in their homes. One resident spoken with had long and dirty nails. Care staff said that she did not like her nails cut but there was no reference to this in the care plan or any guidelines as to how staff should manage it. Her clothes were not fresh and staff said that this was because she had very few clothes in the home. This was also not referred to in the care plans. This is not up to the standard of personal care otherwise seen at this home and all other residents were appropriately dressed and appeared well cared for. A member of staff assisted the resident later in the day to change her clothes and to attend to her nails. Daily records were brief, with little reference to meeting of needs and in the case of one resident who was observed throughout the day, omitted any mention of concerns raised, behaviour demonstrated and activity experienced. The home now has a policy for the administration of Home Remedies to enable ‘over the counter’ medication to be given to residents for minor ailments, without the need to consult a doctor, in a safe manner and with the GP’s agreement. The registered manager advised that a photograph of each resident is now with their Medication Administration Record Sheets for identification purposes and to further safeguarding residents when medication is being administered. This is especially important when non-permanent persons are working in the home. Although the standard related to ‘Dying and Death’ was not fully assessed at this inspection it is worthy of note here that the registered manager advised that she had assisted a resident when her husband was terminally ill by taking her to the hospice and staying there with her until the family were able to get there. This demonstrated sensitivity and respect for the resident and her family. The resident also spoke of the support that she had received from the manager and the staff following her bereavement. A GP visiting the home at the time of the inspection spoke with the inspector and made very positive comments about the standard of service at the home. He said that he was always confident that there would be a senior person in Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 13 charge when he visited the home and that the times that he was asked to visit the home were always appropriate. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Residents are enabled to make choices about daily routines. Residents receive a nutritious and varied choice of food that they enjoy in pleasant surroundings. EVIDENCE: Discussion with residents indicated that they are able to make choices in their daily lives saying that they were able to get up and go to bed when they wish, choose the meal they preferred and whether to join in activities or not. There was no evidence that the residents are involved when changes take place in the décor or refurbishment of the home. Visiting times are at any reasonable time and no restrictions are made. Plastic picnic beakers were in use by residents during the day. These are not appropriate and do not give dignity to the residents. Adult cups or glasses must be used unless a risk assessment for particular individuals indicates otherwise. Residents said that they enjoyed the food, many of them enthusing about the high standard. One resident said that she was vegetarian and that she always Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 15 had tasty meals. Another resident said that she always looked forward to the next meal. The residents said that the cook usually comes to tell them what the meal is at lunchtime, asked them if they wanted this and offered an alternative if not. Offering at least two set choices assists residents to make a preferred choice rather perhaps feeling that they are creating a problem by not wanting the meal offered. At the previous inspection it had been noted that sandwiches were served without the use of tongs. The registered manager advised that new tongs had been purchased and that notices were in place to remind staff to use them. She also felt that the previous incident had been an oversight of a member of staff under pressure created by the inspection. The kitchen was viewed at the end of the day and was clean and in good order. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has a simple complaints procedure that gives the residents the confidence that their complaints will be listened to and action taken. The majority of staff have not undertaken the necessary training to give them the knowledge and skills to identify and prevent abuse. EVIDENCE: The home has an appropriate complaints procedure. Residents spoken with said that they knew who to go to if they had any concerns and that the registered manager would “try to put it right” and were confident that they would be listened to. The registered manager has attended the Local Authority training regarding Adult Protection. She intends to cascade information on to staff but as this training needs to be made directly available to them there are also plans for staff to attend at a later date. The subject is also included in the induction training. A Vulnerable Adult policy is in place although this was not examined on this occasion and a member of staff spoken with was able to list most of the types of abuse and what to do about any suspicion or allegation of abuse. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22,24, 26, An assessment of the premises by a suitably qualified person has been carried out. Although the home is generally safe, clean, pleasant and free of odour there are minor shortfalls that need to be addressed. EVIDENCE: Clarendon Manor is mainly clean, pleasant and free of odour but there were two bedrooms visited that had a very strong malodour that permeated onto the corridor. The main lounge whilst pleasant was very dusty at the time of the inspection. This detracts from the comfort for residents occupying this area of the home and has the real potential to be unhygienic. The registered provider and the registered manager discussed the efforts that had been made to eradicate this odour but having failed may need to consider an alternative floor covering to carpet. Ensuring that appropriate continence management forms part of the care plan for these residents is also necessary. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 18 The carpet in the corridor outside the kitchen is uneven due to the tiles underneath. The registered provider advised that because this is a thoroughfare and used throughout the day the floor can only be repaired during the night. As the area would also need to be well ventilated it had been decided to wait for the warmer weather. A risk assessment needs to be devised and all precautions taken to eliminate any risk. This flooring creates a trip hazard and needs urgent attention. The carpet was in need of cleaning. A carpet in an en suite toilet identified at the inspection was also very dirty and the registered provider advised that it was about to be replaced with a non-slip floor covering. The gardens were pleasant and tidy for the time of year and residents in the smaller lounge spoke of how they enjoy watching and feeding the squirrels and birds that inhabit the garden. A new industrial washing machine has been provided in the laundry and this has a ‘sanitary’ cycle, said by the registered provider to be equivalent of a sluicing cycle. There are no specific temperatures on the dials – warm, very warm, hot etc being used, and therefore it would be difficult for staff to wash garments as per washing instructions and to know if the required 65°C wash is provided. It is assumed that this information is available in the instructions for the machine and this needs to be made available to the staff carrying out the laundry tasks. Soap and fabric hand towels in handwashing areas form a high risk of cross infection and need to be replaced by soap dispensers and disposable towels in order to control infection. The registered provider advised that the organisation is looking at its infection control policy in order to bring it in line with the Department of Health Guidelines on the Control of Infection in Residential and Nursing Homes, as was recommended at a previous inspection. A qualified physiotherapist who is also a partner of the organisation has made an assessment of the home. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The home provides sufficient numbers of staff to meet the needs of the residents. The home has not yet achieved 50 of care staff having NVQ Level 2 in Care, a qualification that demonstrates the competence of care staff to fulfil their role. There are some shortfalls in the recruitment practice creating the potential of inappropriate people being employed. Good progress has been made to provide staff with training opportunities. EVIDENCE: The home provides sufficient numbers of staff to meet the needs of the residents. At the time of the inspection there were three care staff, a team leader, a domestic assistant and a cook working with the manager. There is no designated laundry assistant and care staff carry out the laundry tasks. The time taken by staff to undertake non-care tasks must be identified on the rota to make it clear that these hours are not spent with residents. There is currently a cook vacancy and this is being covered by one of the team leaders and the manager working extra shifts. At the previous inspection the registered manager was covering care assistant deficits and is suggested that she ensures that a work/home life balance is protected. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 20 Residents were complimentary about staff with comments such as, “they are as good as gold”; “everyone is nice and tries to be helpful”; “we are so well treated”; “ I wish I could produce such lovely meals.” Staff were seen to treat residents with respect and interact well with them. The home did not achieve the requirement for a minimum of 50 of the care staff to have NVQ Level 2 in Care by 2005. However there has been some progress with a further 6 staff now undertaking this training. There has also been progress in other training with staff having taken part in training related to Nutrition and Health, Health and Safety, Infection Control, Medication and Moving and Handling. Other mandatory training, fire, first aid and introduction to moving and handling, have been made available on DVD. The registered persons are aware that any training provided on video or DVD needs to be supported by a competent and knowledgeable person. Two lead carers are to attend First Line Management training with the local college and a domestic assistant was included in recent Moving and Handling training as was suggested at the last inspection. This training enables staff to competently meet the needs of the residents. The latest Induction training that meets with National Training Organisation specifications is provided to all new staff. The questions and answers related to the training is completed on the computer and a hard copy kept on file to evidence that the member of staff has completed this training and is competent to work at the home. Not all the information required by Schedule 2 of the Care Home Regulations 2001 was present in all staff files examined, including photographs of the individual, evidence of their physical and mental fitness and up to date Criminal Records Bureau and Protection of Vulnerable Adults checks, some Criminal Records Bureau checks having been brought with the employee from another home. Criminal Records Bureau checks are no longer portable from one service to another, as since July 2005 there is a need for Protection of Vulnerable Adults checks before an appointment is made. Those employees with Criminal Records Bureau (CRB) checks carried out by another service before Clarendon Manor employed the member of staff must have further CRB and POVA checks for Clarendon Manor. No further appointments must be made without a POVA 1st check has been received. A new member of staff may then begin their employment if not doing so creates risk to the residents but must be supervised at all times until a Criminal Records Bureau check has been received. The files examined did not evidence that references had been validated or that gaps in employment had been investigated. These steps are necessary to minimise the risk of inappropriate persons being employed. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36, 38 The registered provider, or representative, does not forward monthly Regulation 26 reports therefore unable to demonstrate that the service provided is monitored. Health and Safety Management, apart from the occasional shortfall is generally satisfactory. EVIDENCE: The registered provider has made some progress in providing the reports required by Regulation 26 of the Care Home Regulations 2001 but continues not to have provided the Commission with these at monthly intervals. The registered provider is reminded that non-compliance is an offence and that it cannot be demonstrated that the organisation is regularly monitoring the service provided at the home. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 22 Surveys are distributed at frequent intervals in order to obtain feedback on the service fro residents and their family and friends. These surveys cover a different area of the service on each occasion, for instance in January general questions were asked; in February the survey concentrated on activities. The organisation carries out an audit on the environment of the home and action appropriately. The registered manager advised that staff supervision is on target to have been carried out six times a year and staff spoken with confirmed this. Records of content of supervision were not examined. At the last inspection it was noted that a resident was in a wheelchair without footrests. As accidental injury can occur with this practice the home was requested to ensure that all wheelchairs had footrests unless a risk assessment suggested otherwise. The registered manager advised that this was now the case and no wheelchairs were seen without footrests during this visit. Hot water taps are fitted with temperature control valves to maintain the water at temperatures of about 43°C to prevent accidental scalding. These temperatures are checked but only at the frequency of one tap a month. is checked. This is insufficient to monitor that hot water remains at about 43°C, each tap needing to be checked at a minimum of once a month or at a frequency recommended by the temperature control valves manufacturer/supplier. Any recommendations need to be available for inspection. As at the last inspection several bedroom doors were wedged open at the time of the inspection. This creates a potential risk in the event of a fire in the home. if a resident wishes a door to be left open a hold open device that is linked to the fire alarm system, and meets with the approval of the Fire Service, needs to be fitted. The registered manager advised and training records confirmed that the majority of staff have undertaken all mandatory training. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 3 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 3 X 2 Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(2)(a) (b) Requirement The registered manager must ensure that all assessments of need are reviewed and appropriately revised at least monthly. The Registered Person must demonstrate that the staff have the skills and knowledge to meet any specialised needs of the service users or provide an action plan demonstrating how this will be achieved. (The previous timescale of 31/12/05 was not met.) The care plans must set out in more detail the action which needs to be taken by care staff to ensure all aspects of the health, personal and social care needs of the service user are met. (The previous timescale of 31/11/05 was not met.) The registered manager must ensure that care staff attend to the personal care of all residents. The registered persons must ensure that cups and glasses appropriate for respected adults DS0000004310.V287038.R01.S.doc Timescale for action 31/05/06 2. OP4 18(1) 30/06/06 3. OP7 15 (1) 30/06/05 4. OP8 12(1) 31/04/06 5. OP15 16(2)(g) 31/04/06 Clarendon Manor Version 5.1 Page 25 6. OP18 13(6) 7. OP18 13(7)(8) 8. OP19OP38 13(4) 9. OP26 12(1) 16(2)(j) (k) are used unless a risk assessment for specific individuals suggests otherwise. The registered persons must ensure that all staff undertake training related to Adult Protection. The registered manager must ensure that any if resident is restricted from undertaking risks against their wishes that this is the only practicable way of securing the welfare and that decision is only taken following multi-disciplinary consultation. The registered provider must ensure that a risk assessment is in place regarding the uneven floor and any action taken to eliminate the risk of trips and falls. The following issues must be addressed – The malodour in bedrooms identified at the time of the inspection must be addressed. Soap dispensers and disposable towels must be provided at communal handwashing areas. The temperature key to the washing machine programmes must be available for staff using the machine. 30/06/06 30/04/06 15/04/06 30/04/06 10. OP28 18(1) 30/06/06 The registered persons must ensure that 50 of the care staff have achieved NVQ Level 2 by 2005. An action plan with timescales as to how this is to be achieved must be forwarded to the Commission for Social Care Inspection in response to this report. (The previous timescale of 31/12/05 was not met.) DS0000004310.V287038.R01.S.doc Version 5.1 Page 26 Clarendon Manor 11. OP29 19 12. OP37 26 13. OP38 23(4) The registered persons must 30/04/06 ensure that the following concerns related to recruitment must be addressed – Protection of Vulnerable Adults and Criminal Records Bureau checks need to be carried out appropriately. References for prospective employees must be validated. Gaps in employment history must be investigated. Evidence that the employee is physically and mentally fit to undertake the job must be provided. The registered provider must 30/04/06 ensure that visits are made to the home under Regulation 26 specifications and a copy of the report sent to the Commission for Social Care Inspection. (The previous timescale of 31/10/05 was not met.) The following health and safety 30/04/06 issues must be addressedThe registered provider, following consultation with the Fire Authority, must provide devices to hold doors open as required, that do not pose a risk in the event of a fire. (The previous timescale of 31/10/05 was not met.) The temperatures of hot water at outlets accessible to residents must be maintained at 43°C and checks made at each outlet at either monthly intervals or to the contractors recommendations. Documented evidence of any recommendations must be available for inspection. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 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. 2. Refer to Standard OP15 OP26 Good Practice Recommendations It is recommended that there is a choice of a minimum of two meals offered each day to residents. It is recommended that the home’s infection control policy and procedures be developed in line with the Department of Health Guidelines on the Control of Infection in Residential and Nursing Homes. Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clarendon Manor DS0000004310.V287038.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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