Inspection on 20/09/06 for Clarendon Mews

This inspection was carried out on 20th September 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 Mews 27/04/09

Clarendon Mews 18/11/08

Clarendon Mews 29/04/08

Clarendon Mews 23/11/07

Clarendon Mews 20/09/05

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 2006 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.V311458.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 Mews DS0000031736.V311458.R01.S.doc Version 5.2 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 No registered manager in place 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 Physical disability over 65 years of age (7) Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No more than 20 persons falling within category DE(E) should be admitted to Clarendon Mews when there are 20 persons of category DE(E) already accommodated No more than 40 persons falling within category OP should be admitted to Clarendon Mews when there are 40 persons of category OP already accommodated No more than 7 persons falling within category PD(E) should be admitted to Clarendon Mews when there are 7 persons of category PD(E) already accommodated The maximum number of persons to be accommodated at Clarendon Mews is 40 20th September 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 forty older persons. The registration allows for up to twenty residents to live in the home who have dementia (under category DE/E). Up to seven residents who are physically disabled (under category PD/E) may live in the home. Clarendon Mews opened in 2002, after a full refurbishment. The home is situated in 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. Fees are set according to the minimum and maximum banding levels of the local social services departments. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included a visit to the service. The inspector visited the home on 20th September 2006. The visit commenced at 9.35am and lasted for six and a half hours. The care manager assisted the inspector during the inspection, and the provider company’s Responsible Individual, Heath Tredell attended to discuss a number of issues raised. The home is currently without a manager, the acting manager having resigned a week before the inspection. The home has been without a registered manager for over eight months. The main method of inspection used was ‘case tracking’. This means looking at the care given to residents in different ways. The ways this was done are: • talking to the residents • talking to staff and the manager • watching how residents are given support • looking at written records. The inspector spoke with seven people who live in the home. In addition, a sample of comment cards were sent out to ten randomly selected service users. Four comments cards were received back for residents. Together with comments from people spoken with during the inspection, these form a sample of views. The views of people living in the home are given throughout the report. In the main, service users were happy about the care given by staff. They felt the home was comfortable and that they mainly have what they need. All the key standards were checked during this inspection. The information below is based only on those aspects checked in this inspection. Individual detail has been kept out of the report, to make sure it is kept confidential. What the service does well: Assessments are carried out for people who wish to move into the home, to check what their needs will be and ensure that staff in the home can meet their needs. Staff have training in different aspects of care, such as dementia awareness, and moving and handling to enable them to give good support to residents. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 6 Care plans are in place for residents, which give information about their likes and dislikes and preferences for their daily living routine. Some aspects of risk relating to residents’ needs were noted and assessed. Accident records are kept in the home.. Daily records and issues logs (where particular concerns are noted) are made. There is a keyworker system in the home, with carers responsible for making sure particular residents have the things they need, such as toiletries. Carers were able to describe needs of residents. Residents spoken with said that they mostly got good support from staff. There is some information in care planning and daily records about people’s preferences for leisure and activities. Residents’ families are able to come into the home. The manager had arranged meetings with families to kept them involved in the running of the home. Residents are able to bring personal possessions into the home. Residents and relatives maintain overall responsibility for residents’ finances. Small amounts of money are held in home on residents’ behalf, to enable them to make small purchases, and have hairdressing and other services. Receipts and records are kept on behalf of residents. The provider undertakes audit checks to ensure that monies are safely kept. Most residents who commented said that they liked the meals in the home. Menus showed a balance and variety in food provided to residents. Residents’ weight and well-being are monitored, and the GP notified about any concerns. There is a complaints procedure in the home, and residents who commented said that they knew how to make a complaint. The manager had appropriately referred one incident of concern to social services and the police, and a proper investigation was carried out. All parts of the premises, which were seen, were clean and tidy, and odourfree. Bathrooms and toilets were clean with equipment in place to aid bathing. Cleaners are employed in the home on a daily basis. Residents spoken with were happy with their bedrooms and the environment generally. Arrangements for washing and drying of laundry remain in place. Most required records about staff employed in the home are in place, including application forms, and evidence of Criminal Records Bureau checks Ongoing training is provided to staff. Four members of staff have started National Vocational Qualifications in care since the last inspection. Training has recently been given to staff in medication administration and first aid. One member of staff spoken with confirmed that she received ongoing training. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 7 Staff meetings are held in the home, for members of staff to give their views about the home and get consistent information about ways of working. Residents are enabled to have input into the inspection process. Safety checks are carried out, and safe working practices are implemented. The cooks and cleaners are doing relevant National Vocational Qualification training. What has improved since the last inspection? What they could do better: Since the last inspection, the Commission for Social Care Inspection granted registration for seven places in the home for people who are physically disabled (PD/E registration category). As part of the registration, the provider was asked to amend the Statement of Purpose to inform people who are looking to move to the home that the en suite facilities in the PD registered rooms are not accessible to wheelchairs, but that there are accessible shared bathroom facilities. This has not been done, and the provider must ensure that it is put into the Statement of Purpose. Care plans were noted to be inconsistent in some cases, in that they contained differing information about the needs of residents. It was also noted relating to residents whose care was tracked that not all issues of concern, which were noted in daily records/issues logs, were then transferred to care plans – so ongoing attention to particular needs of residents had not been given. There were a number of gaps in assessment of risk relating to residents whose care was tracked. Accident records are kept in the home, but there is not evidence of follow up action where a number of falls have been noted. The issues logs have not been signed by staff, which could be problematic in ensuring issues are followed up. It would be good if all records made by staff were signed. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 8 There were some issues noted in case tracking medication administration, highlighting some inaccuracies and gaps in recording. During the inspection there was limited involvement of residents in activities and stimulation. In the afternoon, one carer was involved in a game with residents, but there were long periods of time in which a number of residents with dementia had little or no stimulation. One resident, whose care was tracked, said they were not so keen on the food. It might be good if the provider checks with all residents to find out if they like the food and whether any improvements could be made, to make sure everyone is satisfied. During case tracking of care of residents, a number of serious concerns were highlighted, in which there had been a lack of follow-up investigation and care, and a lack of required reporting to the Commission for Social Care Inspection and other agencies. This had potentially put a number of residents at continuing risk of harm. The provider must ensure that all serious incidents affecting the health or welfare of residents are reported to relevant agencies as required. Records of temperature testing of water at en-suite sinks is carried out – although there was no evidence of action taken where temperature was noted to be higher than the recommended safe level. The provider should ensure that attention is paid to this. One resident said that sometimes he cannot always reach the buzzer - care plans and records indicated that this resident is at risk of falling (see Section 2). The provider should ensure that all residents have good and safe access to call systems. There was only one written reference in place for two members of staff in the home – the provider was aware of this and said he was following it up. The provider should ensure that all relevant checks are carried out before someone is employed in the home. One gap in training, which needs to be looked at further, is how to manage behaviour which challenges, particularly in relation to people who have dementia, and further training in safeguarding adults – again in relation to people who have dementia. The Inspector was informed during the visit to the home that the manager had resigned and left at short notice the week before. It was apparent during the inspection that the provider had not been aware of everything that had been happening in the running of the home over the past few months. The manager had not yet submitted a completed application for registration with the Commission for Social Care Inspection. It is crucial that the provider maintains an overview of how the home is running, particularly in the absence of a Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 9 registered manager. The home has been without a registered manager since December 2005. The providers are expected to carry out a monthly visit to the home to check on standards, and to provide a report of their visit to the Commission for Social Care Inspection (Regulation 26, Care Homes Regulations 2001). The last received reports from the providers relating to this home were of visits carried out in February 2006 and May 2006. The lack of a registered manager and of input from the providers on a regular basis adds to the potential risks for residents. At the last inspection some concern was raised by staff about wearing protective gloves for safe working in infection control. A recommendation was made that staff have training about appropriate wearing of protective clothing in infection control but this has not taken place. From talking to staff, it was clear that there was still some confusion about protective clothing. The provider and care manager confirmed there is no restriction on protective clothing, such as gloves, but that staff are encouraged to use them appropriately. It is still suggested that training is provided, in order that staff can have a proper understanding of appropriate use, and that misunderstandings are minimised. 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.V311458.R01.S.doc Version 5.2 Page 10 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.V311458.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 (St. 6 not applicable in this home) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a mainly good admissions procedure to the home. EVIDENCE: Assessments are carried out for people who wish to move into the home, to check what their needs will be and ensure that staff in the home can meet their needs – assessments are held on care files. Four residents confirmed in comments cards that they received information about the home before they chose to live there. Staff have training in different aspects of care, such as dementia awareness, and moving and handling to enable them to give good support to residents. (But please see section 4 – ‘Complaints and Protection’ and section 6 -‘Staffing’ re training issues). Since the last inspection, the Commission for Social Care Inspection granted registration for seven places in the home for people who are physically disabled (PD/E registration category). As part of the registration, the provider Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 12 was asked to amend the Statement of Purpose to inform people who are looking to move to the home that the en suite facilities in the PD registered rooms are not accessible to wheelchairs, but that there are accessible shared bathroom facilities. This has not been done, and the provider must ensure that it is put into the Statement of Purpose. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 13 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met to some extent, but there are some gaps, which could lead to risk for residents. EVIDENCE: Care plans are in place for residents, which give information about their likes and dislikes and preferences for their daily living routine. However, care plans were noted to be inconsistent in some cases, in that they contained differing information about the needs of residents. It was also noted, relating to residents whose care was tracked, that not all issues of concern, which were noted in daily records/issues logs were then transferred to care plans – so ongoing attention to particular needs of residents had not been given. In some cases, this meant that ongoing attention had not been paid to serious issues of concern, for example relating to management of aggressive behaviour. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 14 Some aspects of risk relating to residents’ needs were noted and assessed. However, there were a number of gaps in assessment of risk relating to residents whose care was tracked, including: proper assessment of the risk of falls, and implementation of a falls prevention programme, assessment of risk of harm from the behaviour of other residents, and assessment of risk of harm of equipment (for example wire of call buzzer found tangled round one resident’s neck). A risk assessment had been carried out within the home for use of bed sides for one resident, but it would be better if this was carried out by the community nurse, who has particular expertise in this area. There was no specific risk assessment relating to the risks of the bedsides themselves, and how these could be minimised. Accident records are kept in the home, but there is not evidence of follow up action where a number of falls have been noted. Daily records and issues logs (where particular concerns are noted) are made, although the issues logs have not been signed by staff, which could be problematic in ensuring issues are followed up. It would be good if all records made by staff were signed. There is a keyworker system in the home, with carers responsible for making sure particular residents have the things they need, such as toiletries. Carers were able to describe needs of residents. Four residents said in comments cards that they always get the care and support they need. Residents spoken with said that they mostly got good support from staff. However, there were some issues noted in case tracking medication administration: - Regarding one resident, an entry in the daily record showed that a medication for a serious heart condition had been lost, but there was no record of follow-up action or investigation. - Regarding one resident, the blister pack containing morning medication given on the day of inspection showed two doses of medicine were still in the pack, but the medication record had been signed to show the medicine had been given. The care manager checked with the responsible member of staff and found that a mistake had been made. Contact was made with the GP to ensure safety for the resident. - Regarding one resident there were some gaps noted in signing for medication, with no evidence found of how this was looked into. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 15 Whilst improvements have been noted, the provider must ensure that medication administration is correct and safe for all residents. Four residents said in comments cards that they always receive the medical support they need. One person commented that they sometimes get the medical support they need. They commented that sometimes they should have cream put on their legs but it is not always done. In the sample checked, the inspector noted that application of creams was recorded. It would be good if the provider carried out a check to ensure that creams/lotions are being applied for all residents who need it. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from some good aspects of daily life, but may be at risk from lack of stimulation. EVIDENCE: There is some information in care planning and daily records about people’s preferences for leisure and activities. During the inspection there was limited involvement of residents in activities and stimulation. In the afternoon, one carer was involved in a game with residents, but the inspector observed that there were long periods of time in which a number of residents with dementia had little or no stimulation. There was no specific attention paid in care plans to particular activities/stimulation to be given to individuals in line with their care needs. Two residents said in comments cards that there are activities arranged by the home that they can always take part in, one resident commented that they can usually take part, and one that they sometimes can. There is an activities board in the home which details activities provided, but those noted on the board were for the month before the inspection. It would be good if the Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 17 provider looked at ways in which more stimulation could be provided to residents. One resident said that a Methodist preacher comes into the home to pray with residents who wish it. Residents’ families are able to come into the home. The manager had arranged meetings with families to kept them involved in the running of the home. Residents are able to bring personal possessions into the home – the inspector saw evidence of personal possessions in residents’ bedrooms. Residents and relatives maintain overall responsibility for residents’ finances. Small amounts of money are held in home on residents’ behalf, to enable them to make small purchases, and have hairdressing and other services. Receipts and records are kept on behalf of residents. The provider undertakes audit checks to ensure that monies are safely kept. Most residents who commented said that they liked the meals in the home. One resident said they were not so keen on the food. It might be good if the provider checks with all residents to find out if they like the food and whether any improvements could be made, to make sure everyone is satisfied. Menus showed a balance and variety in food provided to residents. Residents’ weight and well-being are monitored and the GP notified about any concerns. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although procedures are in place, lack of full implementation means that residents are not sufficiently protected from the risk of abuse or harm. EVIDENCE: There is a complaints procedure in the home, and residents who commented said that they knew how to make a complaint. Four residents stated in comments cards that they always felt that staff listened to them. Four complaints have been received in the home since June 2005, all of which were substantiated, and measures put in place to resolve the issues. The manager investigated concerns forwarded by the Commission for Social Care Inspection and gave feedback about how the home had made improvements following these concerns. Issues were raised about a range of outcome areas including staffing, environment, conduct and management of the home, and personal and health care of residents. One aspect requiring continuing attention is highlighted under section 6, ‘Staffing’. The manager had appropriately referred one incident of concern to social services and the police, and a proper investigation was carried out. However, during case tracking of care of residents, a number of serious concerns were highlighted, in which there had been a lack of follow-up Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 19 investigation and care, and a lack of required reporting to the Commission for Social Care Inspection and other agencies. This had potentially put a number of residents at continuing risk of harm. The provider must ensure that all serious incidents affecting the health or welfare of residents is reported to relevant agencies as required. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 20 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, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents mainly benefit from a good living environment. EVIDENCE: All parts of the premises, which were seen, were clean and tidy, and odourfree. Bathrooms and toilets were clean with equipment in place to aid bathing. Records of temperature testing of water at en-suite sinks is carried out – although there was no evidence of action taken where temperature was noted to be higher than the recommended safe level. The provider should ensure that attention is paid to this. Cleaners are employed in the home on a daily basis. Safety checks are carried out in the home. Records show that required fire safety tests and drills have been carried out regularly, until 6th September Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 21 2006. These had been carried out by the manager, and another responsible individual needs to be identified. Residents spoken with were happy with their bedrooms and the environment generally. One resident said that sometimes he cannot always reach the buzzer - care plans and records indicated that this resident is at risk of falling (see Section 2). The provider should ensure that all residents have good and safe access to call systems. In addition, the bedside lamp (above bed) was hanging off the wall, with no light bulb in it. Given the mobility risks for this resident, it would be good if the provider repaired this. Four residents said in comment cards that they felt the home was always fresh and clean. Arrangements for washing and drying of laundry remain in place. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from mainly well recruited, trained staff, but could be at risk from some gaps in training. EVIDENCE: There were four carers on shift during the inspection, overseen by the care manager. The duty rota shows that generally there are four care staff on duty during the day. There are additional cleaners employed in the home, and cooks employed – although carers help in the kitchen at weekends. Most required records about staff employed in the home are in place, including application forms, and evidence of Criminal Records Bureau checks. There was only one written reference in place for two members of staff in the home – the provider was aware of this and said he was following it up. The provider should ensure that all relevant checks are carried out before someone is employed in the home. Ongoing training is provided to staff. Four members of staff have started National Vocational Qualifications in care since the last inspection. Training has recently been given to staff in medication administration and first aid. One member of staff spoken with confirmed that she received ongoing training. One gap in training, which needs to be looked at further, is how to manage behaviour which challenges, particularly in relation to people who have Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 23 dementia, and further training in safeguarding adults – again in relation to people who have dementia. This was identified in a strategy meeting held following an incident regarding residents in the home, and was further highlighted by issues identified in this inspection (see Section 4 – ‘Complaints and Protection’). Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst some protective measures are in place, residents may be at risk from lack of firm management structures in the home. EVIDENCE: The Inspector was informed during the visit to the home that the manager had resigned and left at short notice the week before. The provider said that a new manager had been appointed who was to start work in a few weeks. The provider stated during the inspection that he had not been fully aware of everything that had been happening in the running of the home over the past few months. The manager had not yet submitted a completed application for registration with the Commission for Social Care Inspection. It is crucial that the provider maintains an overview of how the home is running, particularly in Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 25 the absence of a registered manager. The home has been without a registered manager since December 2005. The providers are expected to carry out a monthly visit to the home to check on standards, and to provide a report of their visit to the Commission for Social Care Inspection (Regulation 26, Care Homes Regulations 2001). The last received reports from the providers relating to this home were of visits carried out in February 2006 and May 2006. The lack of a registered manager and of input from the providers on a regular basis adds to the potential risks for residents. Staff meetings are held in the home, for members of staff to give their views about the home and get consistent information about ways of working. The previous manager set up relatives’ meetings. Questionnaires are provided to gain the views of residents, and other involved agencies about the home – although it was not clear when these had last been collected. Residents are enabled to have input into the inspection process. Written records are in place of all transactions carried out in the home on behalf of residents. The manager and provider have no involvement other than this in the finances of residents. Receipts are in place of monies spent. Safety checks are carried out, and safe working practices are implemented. The cooks and cleaners are doing relevant National Vocational Qualification training. At the last inspection some concern was raised by staff about wearing protective gloves for safe working in infection control. A recommendation was made that staff have training about appropriate wearing of protective clothing in infection control but this has not taken place. From talking to staff, it was clear that there was still some confusion about protective clothing. The provider and care manager confirmed there is no restriction on protective clothing, such as gloves, but that staff are encouraged to use them appropriately. It is still suggested that training is provided, in order that staff can have a proper understanding of appropriate use, and that misunderstandings are minimised. Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X 2 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 3 Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP1 Regulation 4 Requirement The provider must amend the Statement of Purpose to inform people who are looking to move to the home that the en suite facilities in the PD registered rooms are not accessible to wheelchairs, but that there are accessible shared bathroom facilities. The provider must ensure that all issues of concern relating to residents’ health and well being are recorded in care plans and risk assessments. The provider must ensure that there are arrangements in place for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home, in order that residents health and welfare is safeguarded. The provider must ensure that all serious incidents affecting the safety or welfare of residents are reported to the Commission for Social Care Inspection. The provider must ensure that at DS0000031736.V311458.R01.S.doc Timescale for action 30/11/06 2 OP7 OP8 13 31/10/06 3 OP9 13 31/10/06 4 OP18 37 31/10/06 5 OP33 26 31/10/06 Page 28 Clarendon Mews Version 5.2 least monthly checks of the home are carried out and a report prepared, a copy of which is to be provided to the Commission for Social Care Inspection. 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 OP8 2 3 OP12 OP19 Good Practice Recommendations It is strongly recommended that in the absence of a manager, the provider carries out an audit of all care plans to ensure that all needs are identified and appropriate plans and risk assessments are put in place. It is recommended that the provider looks at ways in which residents can be given more stimulation in their daily lives. It is recommended that the provider shows what follow up action is taken where a higher than recommended temperature is found at sinks during water temperature testing. It is recommended that the provider ensures that all relevant checks, including obtaining two written references, are carried out before someone is employed in the home. It is strongly recommended that the provider ensures that all staff receive training in the following areas: - Managing behaviour which challenges staff, particularly in relation to people who have dementia - Safeguarding adults from harm, including reporting requirements and action needed It is strongly recommended that the provider ensures that a registered manager is put in place to manage the home. It continues to be recommended that the provider ensures that care staff receive training about the appropriate wearing of protective clothing 4 OP29 5 OP30 6 7 OP31 OP38 Clarendon Mews DS0000031736.V311458.R01.S.doc Version 5.2 Page 29 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.V311458.R01.S.doc Version 5.2 Page 30 - 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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