Inspection on 20/09/05 for Clarendon Mews

This inspection was carried out on 20th September 2005.

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

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

Other inspections for this house

Clarendon Mews 27/04/09

Clarendon Mews 18/11/08

Clarendon Mews 29/04/08

Clarendon Mews 23/11/07

Clarendon Mews 20/09/06

Clarendon Mews 29/06/05

Clarendon Mews 07/10/04

Clarendon Mews 19/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Clarendon Mews Grasmere Street Leicester Leicestershire LE2 7FS Lead Inspector Chris Wroe Unannounced Inspection 20th September 2005 10:00 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 Mews DS0000031736.V249559.R01.S.doc Version 5.0 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 Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clarendon Mews Address Grasmere Street Leicester Leicestershire LE2 7FS 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) 0116 2552774 0116 2552785 Greentree Enterprises Ltd Mrs Susan Bowley Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (40) of places Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No more than 20 persons falling within category DE(E) may be admitted to the Home when 20 persons of category DE(E) are already accommodated. Service Users falling within category DE(E) are to be accommodated as follows:- 12 residents on the 2nd floor & 8 residents on the 1st floor (annex) To enable residents to be appropriately accommodated and cared for as in condition 2 above staff must be specifically designated during the daytime. There must be a minimum of:- 3 dedicated and appropriately trained staff on 2nd floor, 2 dedicated and appropriately trained staff on 1st floor/annex To admit a named person who is under 65 years named in variation No. 000008966 dated 28 June 2004 29 June 2005 Date of last inspection Brief Description of the Service: Clarendon Mews is a residential Care Home, registered to provide accommodation and care for up to a maximum of forty older persons. The registration allows for up to twenty residents to live in the home who have dementia (under cateory DE/E). Clarendon Mews opened in 2002, after a full refurbishment. The home is situated in a densely populated area of Leicester close to the Royal Infirmary. Bedrooms are located on three floors of the home; a passenger lift services all these levels. Thirty-eight bedrooms have en suite provision, some of those have a bath or shower as well. There are lounge and dining facilities on all three floors of the home. There is a large secure garden within the grounds of the home. The home is well situated for transport routes to the centre of Leicester, and there are local shops within a short distance of the home. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspections carried out by the Commission for Social Care Inspection focus on outcomes for residents. The inspection took place on a weekday, 21st September 2005, starting at 10.00am and lasting for five and a half hours. Residents were present during the inspection, and the inspector spoke with a number of them about how they liked living in the home. The main method of inspection used was ‘case tracking’, which involved selecting three residents and tracking the care they receive through checking records, talking with the residents and with care staff, looking round the home and observing care practices. In addition, a pharmacy inspector carried out an in-depth audit of medication administration systems in the home. Comments and views were given by residents with whom the inspector talked. These included the following: ‘I’m very happy with everything’. ‘I’m treated very well’. ‘I like going to stroke club’. At the last inspection, most of the key standards were checked. At this inspection, the inspector checked the remaining key standards, and followed up requirements and recommendations made at the last inspection. During the inspection an anonymous complaint received by the Commission for Social Care Inspection was also investigated, relating to staff duties and provision of safety equipment for infection control. One part of the complaint was partly upheld, and two parts were not upheld (although these would mainly have been contractual issues between staff and their employer). A Pharmacist Regulation Inspector also attended for four and a half hours of this inspection to appraise the home’s medication handling practises. Evidence was collated and described under Standard 9 of this report. Requirements and recommendations have also been made. What the service does well: The manager shows a very good understanding of the care needs of each resident, and is alert to changes, which might mean extra care or support is needed. Staff also show a good awareness of residents’ needs. Good attention is paid to residents’ physical and mental health, with access to relevant health services. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 6 Residents are treated with respect by staff, and staff have an understanding of how to ensure privacy and dignity are maintained. Residents are enabled to continue to make choices in their lives. Staff receive induction and ongoing training in aspects which are relevant to their role, and which help them to provide good care for residents. Residents’ finances and valuables are safeguarded, and residents have access to services, leisure activities and purchases of their choice. What has improved since the last inspection? What they could do better: Care plans and risk assessments could be enhanced to include particular details about individual care, which needs to be given to each resident, in relation to mental or physical health conditions they have. Improvements must be made in administration and recording of prescribed medication, to ensure medical treatment is properly carried out. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 7 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 Mews DS0000031736.V249559.R01.S.doc Version 5.0 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 Mews DS0000031736.V249559.R01.S.doc Version 5.0 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): All key standards under this section were checked at the last inspection. EVIDENCE: Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9, 10 Residents’ health and personal care needs are mostly well met. A lack of adherence to professional guidance relating to medication practises in care homes means that not all residents are being administered prescribed medication in the safest way or fully following the Prescriber’s intentions which, could lead to treatment failure and possibly a decline in their medical conditions. EVIDENCE: Residents’ physical and mental health care needs are looked after, with access to GPs, district nurses, opticians, podiatric services, and other health assistance. Good attention is given to the well-being of residents, and the manager and staff are able to quickly recognise any problems because of their understanding of each individual. Care plans and records do not always reflect fully the care needs of residents, and further detail could be included to ensure all staff can be fully aware of individual needs. Residents feel that they are treated well by staff. Staff talk about residents with respect, and show respect in their contact with residents. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 11 The Pharmacist Inspector viewed all the ground floor residents’ medication administration record (mar) sheets for the current month and also the previous month for three selected residents. A discussion also took place with two members of staff who would be involved in medication administration. The Pharmacist Inspector was made aware that both these staff members had joined the home in the last month. The majority of the mar sheets indicated that medication had been continually available, missed doses were annotated with the reason and signatures were present to confirm the amount of medication received into the home from the regular supplying Pharmacy was the same as printed on the mar sheet. Shortfalls in administration recording that had been noted included the following: • • • • • • • • Variable doses of analgesics had not been recorded as to what was actually given, for at least 3 residents. Handwritten mar sheets had vital information missing. Usage of removable spare dispensing labels. Alteration to dosage and with no cross-referencing who had changed. Handwritten addition of “WHEN REQUIRED” (PRN) to mar sheets. Not using photographs for verification (present on the care plans). Medication dose (upstairs) was signed on mar as given but tablet remained in the corresponding blister. Medication that had entered the home from another Pharmacy had not been accounted for. It was noted that there is a procedure for maintaining stock counts of Temazepam tablets (classified as a controlled drug) and this ensures that two trained staff are present for administration of this medicine to the resident. Two medication counts were carried out, using the information on how many capsules/tablets were confirmed as received in to the home for a particular resident, and the amounts recorded as given on the mar sheet for that particular supply. Both audits revealed anomalies, as the amounts did not tally. It could be concluded that these courses of antibiotics may not have been administered according to the Prescriber’s instructions. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 12 Medication was being stored appropriately on the downstairs unit; medication that required cold storage was being stored in a locked clinical fridge. Guidance on monitoring the temperature in the fridge and ensuring that it was being regular defrosted was not being followed. The marking of the opening dates of all eye drops in use is not consistent; it was identified that there was an out of date eye drop bottle that was in current use. This was discarded and a fresh supply was already available on the day of the inspection, as the staff had not rotated the new stock that had come in for this resident. In addition it was noted that items that did not necessarily needed to be refrigerated, were being stored in the fridge. Positive steps have been made to ensure that accredited medication handling training is available to those who are designated with the task of administering medication. Out of 19 staff responsible for medicines, 5 had completed this course and 5 where currently on the course. Others would only be allowed to give medicines after the manager or lead carer carried out a period of assessment of competency. It was evidenced that only those staff that have had training by a District Nurse would be delegated the task of injecting insulin. Issues relation to medication and care plans: • • • Limited information on how to handle hypoglycaemia, hyperglycaemia, dietary intake in a diabetic resident. No medication profiles used-hence updates to dosages where not logged but changes in insulin units were seen in text of daily/events logs. Lack of information to follow up the need of emollients /other creams in at risk residents. As this was the first time a Pharmacist inspector had made this assessment at the home, time was given at end of the inspection to verbally feedback issues that raised concerns and advice given on areas of improvements that are required. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents are helped to continue to make choices in their daily lives. EVIDENCE: Residents are able to bring personal possessions with them into the home. Some residents continue to manage their own finances. Staff pay attention to enabling residents to continue to make choices in their daily lives, even where they are less able to through illness or incapacity. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 16 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): 30 Residents benefit from well trained staff. EVIDENCE: Staff receive induction and ongoing training, which helps them provide good care to residents. Training is given in a range of areas, such as safe handling of medication, moving and handling, and dementia care. Staff are paid for training hours, which include in-house training in areas such as fire safety. Residents said that they felt staff knew what they were doing. An anonymous complaint was received by the Commission for Social Care Inspection regarding staff being asked to remain later than their shift without pay, when other staff do not arrive. Whilst this is mainly a contractual issue between employee and employer, implications for the care of residents were considered. Evidence seen during investigation indicated that staff are exceptionally asked to stay longer and that they are paid for doing so. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 17 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): 35, 38 Residents and staff are mainly protected by management and administration procedures. EVIDENCE: Written records are kept of any monies spent on behalf of residents, with receipts kept and signatures of residents or staff obtained to safeguard procedures. Secure facilities are provided for safe-keeping of valuables. An anonymous complaint received at the Commission for Social Care Inspection was investigated during the inspection. The concern was raised that latex gloves were not always available to staff to prevent crosscontamination of infection. Investigation showed that there are times when there are not enough pairs of gloves available, but that there is a training issue Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 18 for staff about appropriate use of gloves to ensure that supplies are not exhausted. The complaint was found to be partly upheld. Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) &17(1)(a) Requirement Ensure that all medication entering the home is appropriately recorded as received, administered (including variable doses) and any balances used for subsequent months are carried forward on the records. The Registered manager must ensure that only in date medication is administered to residents. Eye drops must be dated on opening and discarded after 28 days. All medication is to be administered as prescribed, changes to doses or additional information added must be cross-referenced to care plans. Courses of antibiotics must be continued until completed. The temperature of the clinical fridge must lie between 2-8 ‘C and guidance should be followed on the recording daily of the temperature and defrosting monthly of the fridge. The registered provider must ensure that staff are provided with sufficient stocks of clinically DS0000031736.V249559.R01.S.doc Timescale for action 17/10/05 2 OP9 13(2) 03/10/05 3 OP9 13(2) 03/10/05 4 OP9 13(2) 17/10/05 5 OP38 13 30/09/05 Clarendon Mews Version 5.0 Page 21 recommended protective clothing to assist in prevention of crosscontamination when providing personal care for residents. (previous timescale of 30th July 2005 only partly met). 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 OP9 OP8 OP38 Good Practice Recommendations It is recommended that care plans and risk assessments are enhanced to include particular details about individual care, which needs to be given to each resident, in relation to mental or physical health conditions they have. It is strongly recommended that training is provided to staff in correct use of protective clothing for prevention of cross-contamination, in order that supplies of clothing are appropriately used. All staff to undertake an accredited medication handling course or at least Pharmacist-led training. Each resident to have a medication profile in the care plan. This is to be updated when antibiotics are prescribed or when regular medicine doses are changed. All mar sheets to be verified with a photograph of that resident. Laminated record of all staff signatures kept with the mar sheets as reference. Maintain a list of all staff who have read and agreed to follow the medication policy and procedures. The management team to carry out frequent medication audits to ensure medication is given and recorded accurately. A second trained person must verify all handwritten mar sheets as accurate. 2 3 4 5 6 7 8 9 OP9 OP9 OP9 OP9 OP9 OP9 OP9 Clarendon Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Mews DS0000031736.V249559.R01.S.doc Version 5.0 Page 23 - 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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