Inspection on 23/11/07 for Clarendon Mews

This inspection was carried out on 23rd November 2007.

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 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 20/09/06

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 LE2 7FS Lead Inspector Lesley Allison-White Unannounced Inspection 23rd November 2007 09:30 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.V354745.R02.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.V354745.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clarendon Mews Address Grasmere Street Leicester 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 clarendon-mews@carehomes.uk.net Greentree Enterprises Ltd Georgina Karen Davies Care Home 40 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (40), Physical disability (7) of places Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission are within the following category: Dementia - Code DE. Old age, not falling within any other category - Code OP. 2. Physical disability - Code PD. The maximum number of service users who can be accommodated is 40. 20th September 2006 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 that has 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. Parking facilities are available on the premises. Fees are set according to the minimum (£297.00 per week) and maximum (£383.00 per week) banding levels of the local social services departments. The Commission for Social Care Inspection (CSCI) and Employers Liability certificates were displayed in the hallway at the entrance to the home. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is on outcomes for residents and their views of the service provided. This was an unannounced inspection and took place on a Friday. The primary method of inspection used was “case tracking”. This involved speaking to the residents who use the service provided and looking at three residents care plans. The inspection focussed on checking existing records kept in the home, talking to residents, their relatives and the staff and observing care practices in some cases. There were twenty-four residents at the home at this inspection. In planning for this inspection questionnaires were sent to residents and their relatives. The response was good. The service history was also used. The Annual Quality Assurance Assessment form (AQQA, current information about the service) was received from the provider. At this inspection not all the key National Minimum Standards were met. The Registered person facilitated this inspection. What the service does well: Residents’ comments ‘All the staff are helpful, friendly and work as a team. This is mainly due to the Registered Manager.’ Relative comments ‘I have always found staff to be well informed of various procedures’. ‘Mrs X has never had cause to complain, but I feel that any concerns would be adequately dealt with.’ ‘Staff all seems kindly and caring’. ‘Staff will keep you well informed of any problems or difficulties.’ ‘Most staff are friendly and approachable.’ ‘I feel the carers do well. I would not like to do that job.’ ‘I feel that the staff provide a loving environment’. ‘I feel that the staff knows each person individually. Staff are very welcoming and friendly.’ Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users moving into this home will have an assessment done although this could include more detail. EVIDENCE: The Registered Manager explained that the Service Users Guide and Statement of Purpose. (This is information about what the service can provide) is not available as it is being reprinted in preparation for the planned rehabilitation care services to be offered in full at this home. The inspector case tracked three residents including two new people. (This is looking at the care plans for each of the residents to see if the care and social assessments provide sufficient detail for care be carried out effectively). Family members who spoke to the inspector said that as a result of printing they did not have access to a Service User Guide or Statement of Purpose. There was no assessment done in advance by the Registered Manager of the Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 9 home for one of the new people. The assessment about this new resident was limited. The Registered Manager has since explained that the assessment was not done by her, this may explain the information that was not apparent for this resident. A requirement with regard to assessments will be made. The other new resident was expected to be staying at the home and there was evidence of typed assessments having been done. An assessment was in place for the third resident case tracked also. Standard 6 is now being offered at this home. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Health, personal and social needs are not always met for residents living at this home. EVIDENCE: Not all care plans were up to the same standards. One of the case tracked residents care plan had typed information in it however parts of the care plan was not completed. The Registered Manager may wish to ensure that all the necessary details about a resident is included in all parts of the care plan. A falls assessment was included along with nutritional assessments and other assessments. In contrast another new resident case tracked did not have a falls assessment in the plan of care to give staff guidance as to what to do when the resident had a fall. The resident had been in the home just a couple of days before experiencing their first fall and this resulted in a minor injury. In the absence of Registered Nurses at this residential home, it was not made clear as to when or who was qualified to make the judgements on when the Doctor or District Nurses would be asked to see a resident following an injury or fall at the home. The record keeping of follow up was not evident either. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 11 The information about the resident in the care plan mentioned that the resident wandered and needed the assistance of one or two care staff as the resident was confused at times. This resident was brought to the lounge when their visitors had left by a member of staff. The resident looked unsettled in the large lounge and did not settle. As the care staff member was leaving the room the resident also got up to leave the room. If a full history of the residents needs, likes and dislikes had been done. The staff would have discovered that the resident did not like large spaces and related to the small lounge as it reminded them of their own lounge at home. The care plan recorded that the resident wandered and needed assistance when required. However when the resident wanted help, there was no one available for them to call out to, or to make staff aware of their needs. Call systems within the lounges were not easily accessible or easily identifiable within the lounge areas. Relatives’ comments included ‘Hospital appointments are usually forwarded on. The General Practitioner (GP) visits regularly; though on odd occasions we do not get information from these visits. Annual reviews are somewhat closed cases. Review officers change each year and sometimes appointments are made with the home but relevant dates etc are not passed on to the family.’ ‘Information agreed to at annual reviews are not always met mainly due to staffing shortages.’ ‘The care given to X is more than adequate, and staff will always keep X informed regarding any treatment or medication that is required.’ An apron was placed on a resident to wear whilst they took their drink independently. The apron did not fasten, as it was broken, it kept falling from around the resident’s neck. This did not improve the dignity of the resident who spoke with the inspector. The staff member was aware that it did not fasten when it was put on, as she was unable to close the press-studs on it. (This does not show in practical terms daily regard to respect or awareness of the resident’s dignity.) Other comments from relatives included ‘Staff all seems kindly and caring’. ‘Staff will keep you well informed of any problems or difficulties.’ ‘Most staff is friendly and approachable.’ ‘I feel the carers do well. I would not like to do that job.’ ‘I feel that the staff provide a loving environment’. ‘I feel that the staff knows each person individually. Staff is very welcoming and friendly.’ Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 12 The supplying pharmacist checked medications at this home in July 2007 and listed three errors. Three different errors are listed in this report. On this key inspection liquid medicines written, as twice-daily amount 5-10mls did not record whether 5mls or 10mls had been given to the resident. Another drug was out of stock 22/11/07 and 23/11/07 the cupboards were checked and the reorder book was checked. The Registered Manager was called to witness this and then was asked to reorder the medication for the resident to have as there was none in stock and it was before a weekend. Ferrous Sulphate 200mg take one was crossed out from three to two times per day. This resident had been to hospital recently and had had their medications changed at the hospital. The medicine kardex was altered according to the new instructions but failed to state where the instruction had come from. The staff explained that it was on the letter from the hospital but this information was not transferred to the medicine kardex for staff to see and check for themselves. A heart medication known as Digoxin 62.5 mg was increased to 125mcg. There was no evidenced that the change had triggered a re order process by the staff and there was no mention of a daily pulse check prior to the medication being given. The Registered Manger has said that a local General Practitioner (GP) has explained that there is no benefit to doing this and this explains why this is not practised. The Registered Manager can verify that the staff giving medications has received some training in this area. (A medicine kardex is a file containing medicine sheets). A requirement for improvements in the management of medications will be made in this area. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not find that staff at Clarendon Mews are able to meet their cultural, social or recreational needs although for residents who have families contact with them is well maintained. EVIDENCE: The new residents’ received regular visitors and group activities were not very important to them their families explained. The third resident spent most of their day smoking and felt bored by the lack of meaningful activities provided at the home. More than one resident said that they did not think that the food provided at the home met their needs and did not get offered interesting or different foods. On one occasion this had been discussed at a review meeting. There was no evidence of this having been followed up or changed by the Registered Manager. Question asked by inspector do you like the meals at the home? ‘I only eat small amounts of food and would like to have more fresh food such as vegetables rather than tinned or frozen food, also I don’t like fish cakes and the burgers that we are given.’ Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 14 ‘Sometimes I do not like the meals, not much change’. A meal time was observed by the inspector and appeared satisfactory two meal choices were available and a choice of hot or cold sweet however for residents with memory problems a menu board in the dining room would assist people remember what the meals are for the day. An activities coordinator is employed by the home however the activities coordinator is unable to be at the home full time as this person is shared with another care home within this same group of care homes. As a result staff attempt to improvise activities with residents although this may not always be successful. A recommendation has been made in this area. A staff member was seen asking residents for their permission to place a cloth over their eyes and to guess what she had placed in their hand. To people suffering with dementia this may not be useful and could actually frighten them. They may not have the words to describe the object and by not being able to see what they are touching this could bring about a fearful reaction. Later the staff member went on to play another guessing game where no one needed to be blindfolded. The staff member’s attempts to provide activities for residents with a memory or communication problem demonstrated not only a lack of awareness of activities more suitable for the different conditions within the resident group seen at inspection but also a lack of appropriate training in this area of resident need. Resident’ comments included ‘I was lead to believe that a mini bus would be provided for trips out. I have been here 5 years and been out twice.’ ‘Wherever possible the staff help but are not always able to act straight away.’ (This resident has failing eyesight) ‘When I try and tell them something I feel they are walking away. There are certain members of staff who do listen, others don’t they just walk away.’ Question asked by inspector. Are there activities arranged by the home that you can take part in? Residents’ comments included ‘Not enough’ ‘Yes if I wanted to take part.’ ‘There are some activities but I do not join in very often as I prefer to sit and read or sometimes watch TV in my room.’ ‘There is nothing that I can do. What I could do I’ve lost the ability to do due to poor eyesight.’ (This resident has failing eyesight). Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 15 Relatives said that they were made to feel welcome although sometimes information about their relative was not always passed on to them. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives felt that the registered manager would act on their concerns. EVIDENCE: The Commission for Social Care Inspection (CSCI) has received two concerns about Clarendon Mews. The Registered Manager was able to demonstrate that she has an awareness of when to report incidents to CSCI however on examination of the accident book and on examining the care plans it was noticed that follow up of actions taken following falls was not always well recorded. A requirement will be made for this area of concern. Question asked by inspector do you know how to make a complaint? Residents’ comments included ‘Yes but I have never has need to.’ ‘There is usually somebody I can speak to.’ ‘Everybody would hear about it if I weren’t happy: but the staff are all nice to me.’ ‘I do have a key worker who is lovely but when she is on holiday I do not know who to ask as often the messages are not passed on’. The Registered Manager explained that she records the amount of accidents at the end of each month. She explained that she has received help from a falls Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 17 prevention advisor. Staff continues to receive training in various aspects of care. Relatives who spoke with the inspector felt that the Registered Manager was approachable and felt that their concerns would be listened to and acted on. Two staff records were checked at inspection and although there was evidence of improvements in this area as a result of the requirements in the last inspection report. The Registered Manager should continue to check all staff records old and new to ensure that they all comply with the Care Standards Act 2000. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment is not well maintained and it is not hygienic. EVIDENCE: The bedroom doors were closed or locked by the residents case tracked and were not seen by the inspector but residents or their relatives who spoke to the inspector said that they liked their room. The downstairs female toilets did not have any soap in them or paper towels. The inspector spoke to the Registered Manager about this on arrival and it was immediately dealt with. The toilet areas for both male and female residents were poorly decorated and the visitors’ toilet area also lacked improvement. In the dining room used by residents a part of the wall plastering was missing. The general décor of the place was adequate. A decorator and other visiting maintenance staff were working at the time of the inspection. They were Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 19 working on the upstairs part of the home where the new rehabilitation places are expected to go. A domestic was seen on duty cleaning the home. The Registered Manager explained that there is normally two staff on duty but the staff member was on holiday and no replacement had been found. An upstairs toilet area (T6) was visited by the inspector. The soap dispenser had no bottom part to it, there were no paper towels to dry hands and the electric hand drier was switched off. This does not encourage good practices of hygiene for either residents or staff attending to residents. In certain places of the larger downstairs lounge the smell of soiled seating was noticed and a visitor advised the inspector to use a dry chair from the dining room nearby as they had done. This clearly was not a ‘one off’ incident of soiling and inappropriate cleaning measures after such accidents. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager continues to make improvements in the area of staffing to ensure that residents’ will benefit. EVIDENCE: Relative comments ‘I have always found staff to be well informed of various procedures’. The inspector saw the rota. Staff were employed to cover the different areas such as domestic or care staff. Sometimes staff was shared in the different areas. The catering assistant would be a carer when needed on another shift. There was no maintenance person on the day of inspection as he was shared with another home within the group. The residents sat in the lounge unsupervised and staff visited at intervals such as drinks time or prior to lunchtime. If residents needed assistance it may be difficult for them to obtain this with out the help of visitors. Staff training included adult awareness, Protection Of Vulnerable Adults (POVA); safe handling of medicines, and eight staff was selected for a twelveweek distance-learning course in Equalities and Diversity. Some staff had a National Vocational Qualification (NVQ) level 2 in care or above. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 21 On the day of inspection staff were seen coming in to see the external NVQ teacher. This showed a commitment to improve their learning in care issues. Staff has mentioned that they feel that there is a need for more staff and some have included this within their supervisory meetings. The two staff records seen by the inspector had Criminal Records Bureau (CRB) checks in them. A review of staffing levels will be made a requirement. The Registered Provider must demonstrate how the current staffing levels at Clarendon Mews meets the needs of all the current service users. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The financial interests of the residents’ are safeguarded. EVIDENCE: Residents’ comments included ‘All the staff are helpful, friendly and work as a team. This is mainly due to the Registered Manager.’ The Registered Provider now ensures that monthly checks of the home are carried out and a report prepared. A copy is available for the Commission for Social Care Inspection to see. A Registered Manager is now in place to manage the home. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 23 There is no secretarial support at this home and this may be preventing the Registered Manager from being able to carry out her duties effectively however the Registered Manager feels that she is able to mange well without this support and will review this when it becomes necessary. The finance of one resident was checked and fine. The Registered Provider makes regular checks on this aspect of care it was last checked 29.09.07. The Registered Manager said that the fire checks were up to date. Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 24 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 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Timescale for action 31/01/08 2. OP8 13 3. OP9 13 4. OP15 16 (i) All service users entering the home must receive a suitable assessment and staff must read the assessments to ensure that they carry out the measures identified within it. The provider must ensure that 31/01/08 service users receive, where necessary, treatment, advice and other services from any health care professional. Repeated from 19/02/07 as not satisfactory. The provider must ensure that 31/12/07 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. 19/02/07 some improvements have been made but it is not satisfactory. This is repeated. Meals must be sufficiently 31/01/08 interesting to appeal to residents living at the home and where individuals have expressed a preference this should be acted DS0000031736.V354745.R02.S.doc Version 5.2 Clarendon Mews Page 26 5. OP18 37 6. 7. OP18 OP26 37 13 (3) 8. OP27 18 (1) (a) on. The provider must ensure that all serious incidents affecting the safety or welfare of residents are reported to the Commission for Social Care Inspection. (CSCI) Previously 19/02/07 now repeated. A list of all falls and accidents in this home must now be sent to CSCI until further notice. The environment used by residents must be clean and safe eliminating the risks of cross infection. Adequate washing, drying and disposal facilities must be provided for residents, staff and visitors to use. Staffing levels and proof of flexibility within the rota must allow for residents who need to have more time spent with them due to their conditions. 31/12/07 31/12/07 31/01/08 31/01/08 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 OP12 Good Practice Recommendations It is recommended that the provider continues to look at ways in which residents can be given more stimulation in their daily lives. A copy of the Service User Guide and Statement Of Purpose should be sent to the Commission for Social Care Inspection. Registered Manager should continue to check all staff records old and new to ensure that they all comply with the Care Standards Act 2000. 2. 3. OP1 OP28 Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clarendon Mews DS0000031736.V354745.R02.S.doc Version 5.2 Page 28 - 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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