Inspection on 29/04/08 for Clarendon Mews

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

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 23/11/07

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

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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 29th April 2008 11:00 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.V363427.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.V363427.R01.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.V363427.R01.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. 23rd November 2007 Date of last inspection Brief Description of the Service: Clarendon Mews is a residential care home. It is registered to provide accommodation for a total of forty older people. The registration also allows for up to forty people to live in the home that has dementia (under category DE). It also allows for people who are physically disabled (under category PD) to 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 (£286.00 per week) and maximum (£396.00 per week) banding levels of the local social services departments. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 5 The Commission for Social Care Inspection (CSCI) and Employers Liability certificates were displayed in the hallway near the entrance to the home. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. The home provides care for up to forty people. On the day of inspection there were 19 people living at the home. The inspection took six hours to complete. Preparation included examining inspection records and looking at the service history. This aided the inspection process by providing background information. Discussion was held with five people who lived there. Two people had memory problems and limited communication skills and indicated how they felt when asked questions. The primary method of inspection used was “case tracking”. This involved speaking with the people who use the service provided, looking at two peoples care plans and making observations. (Care plans are records about the care or support provided for an individual). All the required key standards were inspected during this visit. Previous concerns were dealt and new requirements were made at this inspection. The Registered Manager and the Registered Provider assisted during the inspection. What the service does well: Regulation 37’s (this is information that affects the well being of anyone living in a care home that may need further follow up or action) are now sent into the Commission for Social Care Inspection (CSCI) and any concerns have been followed up at inspection. Accidents are regularly recorded and a list of falls/ accidents is sent to CSCI as requested each month until further notice. The Registered Manager is aware of her responsibilities. Staffing levels have been improved. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 7 People living at the home who spoke with the inspector felt they were able to take their concerns to the Registered Manager and felt they would be acted on. The staff rota has been revised and seems to be working well. An increase in staffing numbers has been provided. The Registered Manager supports a staff team who have been recruited and trained to continually support the people who live there to a satisfactory standard. 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.V363427.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: Two people were case tracked at this inspection. Both had evidence of preassessments to meet their needs. The forms included health, personal and social care details about each of them. Communication problems were identified, any aids used by the individual, family contacts or close friends and health care contacts were recorded. The Statement of Purpose states that the home provides up to sixteen bedrooms for the Primary Care Trust to enable them to undertake rehabilitation services to the clients under their care. The home does not provide care directly to these clients but offer hospitality services. Standard 6 falls within this category. Clarendon Mews DS0000031736.V363427.R01.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff at Clarendon Mews delivers appropriate care to individuals living at the home. Individuals’ physical and mental health care needs are met. However, further improvement in the evaluation of care needs is required. EVIDENCE: Improvements are being made. The General Practitioner (GP) visits every Wednesday to check if there are any medical issues. Everyone living at the home has access to the dentists, opticians and other community services as required. It was noticed that one person frequently refused or was unable to take their strong analgesia. On discussion with the Registered Manager it was suggested that she discussed the option of having the analgesia offered in an alternative form that may be more suitable for this person. One person has aggressive out bursts the Registered Manager contacted Social Services for advice this was recorded in the care records and appropriate action will follow. CSCI were also Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 11 informed. The staff has followed an informal action plan since the incident. It takes into account the needs of other people working and living at the home. The Registered Manager continues to monitor and review the situation and has involved the Social work team when a decision about the individual has been made. One of the people case tracked was selected following an event mentioned in a Regulation 37 sent to CSCI. A Regulation 37, is a notification form sent to the Commission for Social Care Inspection (CSCI) in the event of death, illness or other events causing changes to an individual). The person suffers with low blood glucose although not diagnosed as being a diabetic. Follow up of their condition was kept on their record. (On the chart staff wrote what food and fluid the individual took for a few days in detail then continued within a normal routine for the home.) Further checks could have been requested as it may be that the individual was an undiagnosed diabetic and may benefit from being offered something to eat as soon as they get up in the morning as the staff may find that their behaviour may change. This was discussed at inspection and the Registered Manager said that she would add the person to the GP list. The Registered Manager explained that this person no longer had a particular diagnoses seen on the care records. This information was still written in the care plan as being relevant as it has not been altered by anyone. It is important to ensure that information relating to the people living at the home is evaluated as necessary to reflect their current needs as potentially the wrong diagnosis and treatment could be offered. People’s health is monitored and appropriate action is taken. The home should continue to seek professional advice on health care issues from the relevant services. Where people were transported in wheelchairs footplates were used although some footplates seem to be in need of attention as they were difficult to fold back. The home has a medication policy which is accessible to staff, medication records are generally up to date for each person and medicines received, administered and disposed of are recorded. Where medication systems are in need of action the registered person is working towards improvement. The fridge for the storage of medicines was broken and not in use. It is important that this is replaced or repaired to ensue the safe storage and administration of medicines at all times. This will be a recommendation. Other Regulation 37’s were seen. Improvements are being made to the recording and monitoring of people following an adverse event. Further monitoring will continue. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home find their expectation matches their lifestyle. EVIDENCE: Music was being played in the lounge and the people in the room appeared quiet and undisturbed. Other people found their own means of entertainment. The inspector spoke with both kitchen staff. The cook explained her role and the safety measures that she took each day to ensure that the food provided was cooked and served in a safe manner. Home baked cakes were also provided. The cook was able to explain how she would meet the needs of people with special diets. The kitchen appeared clean and well used. There appeared to be sufficient food in the fridges for people to eat. The cook’s protective clothing looked as if it needed washing and she explained that she had one outfit. It will be a recommendation that the Registered Provider ensures that the kitchen staff are provided with a sufficient supply of clean clothing for them to wear when meals are being prepared. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 13 A lunchtime meal was seen. It included two choices of main meal. When served it looked pleasant and people who ate it said that they enjoyed their meal and the other meals provided at the home. The staff was seen helping people who needed assistance. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff is aware of the need to protect residents from harm and feel able to seek appropriate advice or help to do so. EVIDENCE: The Commission for Social Care Inspection (CSCI) has received a complaint about the care home since the last inspection report. The Registered Manager has also received a complaint. The complaint was shown to the inspector. The Registered Manager dealt with this appropriately. Regulation 37’s are now sent into CSCI and any concerns have been followed up at inspection. Accidents are regularly recorded and a list of falls/ accidents is sent to CSCI as requested each month until further notice. The Registered Manager is aware of her responsibilities. Staffing levels have been improved. People living at the home who spoke with the inspector felt they were able to take their concerns to the Registered Manager and felt they would be acted on. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and pleasant. EVIDENCE: Improvements are being made and will be on-going. Public areas such as downstairs toilets have been refurbished. Facilities for ensuring that people can wash and dry their hands are now provided with disposal facilities. A new office has been provided near to the reception area for the manager to use. New chairs have been provided in the lounge area and the dining room looks very pleasant. A new hairdressing room is in progress for the people living there to use. An upstairs bedroom was seen. It was pleasant having ensuite facilities provided. The pedal bin in the kitchen needs to be replaced to ensure health, Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 16 safety and cleanliness in the kitchen at all times. The maintenance person was made aware of this at inspection. This will be a recommendation. Significant changes to the environment make the home a more pleasant place for people to live in. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home felt satisfied with the staff that cares for them. Rotas have been improved to better reflect the changing needs of the residents. EVIDENCE: The staff rota has been revised and seems to be working well. An increase in staffing numbers has been provided. There is no written policy on escorting people to hospital and it can cause confusion to both relatives and staff, as people are not sure what to expect. This may be something that the Registered Provider may wish to consider. The number of falls and accidents are still being monitored and an improvement in the welfare of the people living at Clarendon Mews will become clearer. A Random inspection took place on 10.03.08 and the staffing issues had already been addressed then. Staff records were checked at this inspection and they were satisfactory following good recruitment practices in all areas. At inspection a few staff were asked to speak with the inspector. They were knowledgeable in most areas of care however, some staff would benefit from a refresher in the Protection Of Vulnerable Adults (POVA) training. At inspection Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 18 the Registered Manager contacted the training people and staff have been booked to attend the Protection Of Vulnerable Adults (POVA) training and challenging behaviour training within the next 2 months. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for the people who live there. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager supports a staff team who have been recruited and trained to continually support the people who live there to a satisfactory standard. EVIDENCE: Record keeping is improving and is of a good standard and is now routinely completed. Where issues have been identified, for example, in care plans, these have mainly been acted upon to ensure that the care of the people living there is not compromised. The people who live at Clarendon Mews are aware of safety arrangements and have confidence in the safe working practices of the staff. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 20 Where the home is responsible for a person’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. The Registered Manager said that the health and safety aspects of the home were up to date. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 14 (2) (b) Requirement It is important to ensure that information relating to the people living at the home is evaluated as necessary to reflect their current needs as potentially the wrong diagnosis and treatment could be offered. Timescale for action 30/06/08 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. 2. 3. Refer to Standard OP9 OP12 OP38 Good Practice Recommendations It is recommended that the registered provider replaces or repairs the medication fridge to ensure the safe storage of medicines. It is recommended that the provider continue to look at ways in which residents can be given more stimulation in their daily lives. It is recommended that the pedal bin in the kitchen area be replaced to ensure the health and safety with reference to the disposal of food. Clarendon Mews DS0000031736.V363427.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V363427.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!