Inspection on 29/06/05 for Clarendon Mews

This inspection was carried out on 29th June 2005.

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

The inspector 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 20/09/06

Clarendon Mews 20/09/05

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 29 June 2005 at 1.00pm 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 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 C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clarendon Mews Address Grasmere Street Leicester Telephone number Fax number Email 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 Susan Bowley Care Home 40 Category(ies) of Op - Older Persons - 40 registration, with number DE(E) - Dementia over 65 years of age - 20 of places Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 20 persons falling within category DE(E) may be admitted to the home when 20 persons of category DE(E) are already accommodated. 2. Service users falling within category DE(E) are to be accommodated as follows: - 12 residents on the 2nd floor and 8 residents on the 1st floor (annex). 3. To enable residents to be appropriately accommodated and cared for as in condition 2 above, staff must be specifically designated during the daytime. 4. There must be a minimum of:- 3 dedicated and appropriately trained staff on 2nd floor, 2 dedicated an appropriately trained staff on 1st floor/annex. 5. To admit a named person who is under 65 years named in variation No. 000008966 dated 28 June 2004. Date of last inspection 17th October 2004 Brief Description of the Service: Clarendon Mews is a residential Care Home, registered to provide accommodation and care for up to a maximum of forty older persons. The registration allows for up to twenty residents to live in the home who have dementia (under cateory DE/E). Clarendon Mews opened in 2002, after a full refurbishment. The home is situated in a densely populated area of Leicester close to the Royal Infirmary. Bedrooms are located on three floors of the home; a passenger lift services all these levels. Thirty-eight bedrooms have en suite provision, some of those have a bath or shower as well. There are lounge and dining facilities on all three floors of the home. There is a large secure garden within the grounds of the home. The home is well situated for transport routes to the centre of Leicester, and there are local shops within a short distance of the home. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a weekday, 29th June 2005, starting at 9.50am and lasting for six hours. Residents were present during the inspection, and the inspector spoke with a number of them about how they liked living in the home. The main method of inspection used was ‘case tracking’, which involved selecting four residents and tracking the care they receive through checking records, talking with the residents and with care staff, looking round the home and observing care practices. Requirements and recommendations made at this inspection relate to information gathered through case tracking. Comments and views were given by ten residents with whom the inspector talked. These included the following: ‘I can’t fault it’. ‘I’m very happy here’. ‘I like watching the squirrels run across the trees.’ Comments cards, sent out to gain residents’ and relatives’ views of the home, were received from one resident and ten relatives. These gave mostly positive responses to questions about care and services. One relative commented: ‘When I visit there always seem adequate staff… It is just as important that the staff are caring and competent. I feel that this is the case at Clarendon Mews.’ During the inspection an anonymous complaint received by the Commission for Social Care Inspection was also investigated, relating to staffing levels. The complaint was found to be not upheld. What the service does well: Assessments are carried out before people come to live in the home, and care plans prepared after they have come in to the home. Care plans and information about residents provides a good picture of their needs. Attention is paid to particular health needs of individuals. Residents described that they felt well looked after. Visitors are welcomed into the home and residents encouraged to have contact with relatives. Choice is offered at mealtimes. Residents have the opportunity to socialise both at mealtimes and throughout the day. Various activities are held from time to time in the home and there are occasional trips out for residents who prefer. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 6 Policies and procedures are in place in the home to deal with a whole range of issues, from infection control to protection of vulnerable adults and complaints. Complaints are addressed and any improvements needed are brought to the attention of staff. The manager continually strives to ensure standards are raised in the home. The premises are clean, tidy and well maintained. Recruitment processes are in order, and staff receive training on an ongoing basis. Staff are supervised in their work. Staffing levels on the day of inspection reflected the dependency levels of residents. What has improved since the last inspection? What they could do better: Administration of medication systems must be improved, to ensure that there are no gaps in recording. Staff in the home must monitor more closely any behaviour of residents which may have a detrimental impact on other residents and take steps to ensure this does not happen. Staff must be provided with clinically recommended protective clothing to assist in prevention of cross-contamination when providing personal care for residents. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 7 It is recommended that the choice of a cooked breakfast is offered again to residents to ensure that residents have greater choice – the manager said this would happen within one month of the inspection. It is recommended that training relating to protection of vulnerable adults from abuse is provided to staff to increase their awareness and understanding. 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 C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5 Good information, assessment and the opportunity to visit enable residents to make an informed choice about moving to the home. EVIDENCE: The service user guide provides good information to residents about life in the home. Assessments are carried out for people who wish to come and live in the home. Attention in assessment is paid to residents’ social and emotional needs as well as physical and medical needs. People who would like to come and live in the home are able to visit the home initially – a visit took place during the inspection. One resident told the inspector that they had come to the home for a trial visit. The resident said that first impressions, on coming to live in the home, were ‘good’. The home does not provide intermediate care, and so standard 6 is not applicable. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 10 Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 Health and personal care needs are partly met, but errors in medication administration mean that residents’ well-being is not wholly safeguarded. EVIDENCE: Each resident has a personal care plan, which describes their care needs and wishes for daily living. Information includes risk assessments relating to particular areas of vulnerability for residents, including falls prevention. Signed records showed that care plans are reviewed regularly. Policies are in place detailing how medication should be stored and given. Staff who give out medication have received training. Medication checks showed a number of gaps in recording of administration, including where this could have a serious impact on a resident’s health. The manager showed that staff had identified medication administration as an issue requiring attention and monitoring. Measures had been about to be introduced to tighten procedures, but the identified lead member of staff had gone off sick. The attempts of the manager are acknowledged, and she must make sure that these improvements are carried through forthwith. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 12 Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Residents mainly benefit from arrangements for daily life and social activities, but there are some aspects of meal provision which detract from full enjoyment. EVIDENCE: Residents are involved in different activities, according to their choice and the capacity of the home to provide a range of leisure pursuits. The manager has occasional use of a company minibus, which is used to provide trips, for example to a local garden centre. A newsletter available for residents details activities, which have taken place, such as making chocolate cakes, and singing and dancing. One relative commented in a comment card that they would like more stimulating activities to be provided in the lounge for residents who have dementia. During the inspection, some members of staff played a ball throwing and catching game with residents. One resident talked about going out to the local pub. A recent development has been made to make one member of staff the lead on activities in the home, to ensure they take place as intended. Visitors were seen coming into the home during the inspection to see residents, and residents talked about visits from their families. The newsletter and regular questionnaires give relatives the chance to be involved with the home. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 14 Menus were seen, which showed that a main meal is offered to residents, and a basic alternative option if they prefer – on the day of the inspection, lunch was chicken casserole, with an alternative of beefburger offered. Fridge, freezer and dry food stocks showed sufficient shorter-term supplies – the cook said a food delivery was shortly due. Fresh fruit is available in the home. Most residents spoken with said that they enjoyed the food in the home – one resident said that there were ‘sometimes good days, sometimes not so good days’. The cook provides alternatives where a particular diet is needed, for example gluten-free, and stocks of relevant products were in place. One resident said that he enjoys having a cooked breakfast, but the manager said that the option of a cooked breakfast was not provided at present, because a new cook had recently been employed (six months ago) and was ‘getting into the swing of things’. She said that a cooked breakfast would be available again within a month of the inspection. Lunch begins at about 12pm, and tea is offered at 5pm. The inspector observed that tea and biscuits were given during the afternoon, but that only one biscuit was given out to each resident. The manager said that there was no specific dietary reason for this and that residents should be offered biscuits and be able to choose to have one or more if they wish. It is recommended that attention is paid to this to ensure that staff can meet the wishes of residents. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 15 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 standard(s) 16, 18 Residents’ well-being is mostly promoted and protected by complaints and adult protection procedures. EVIDENCE: A complaints procedure is in place in the home, and records showed that the manager deals with complaints appropriately and takes matters seriously. Issues raised by residents and relatives have been followed up. Residents said that they felt able to talk to staff or to the manager about concerns. One resident said that she was concerned because another resident wandered at night and came into her room – she said she had told staff but they said there was nothing they could do. The manager said that this would be looked into and sorted out – she notified the Commission for Social Care Inspection as to action that had been taken prior to publication of the report. Staff in the home must monitor more closely any behaviour of residents which may have a detrimental impact on other residents and take steps to ensure this does not happen. During the inspection an anonymous complaint, which had been raised with the Commission for Social Care Inspection (CSCI), was looked into, relating to staffing levels. Staffing levels were found to be sufficient during the inspection, and the complaint not upheld. A complaint relating to care of residents with MRSA had also been raised with the CSCI since the last inspection. A response had been provided by the home, but at inspection there remained issues of concern relating to this, which are raised under standard 38. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 16 There are policies in place in the home relating to protection of vulnerable adults from abuse and whistleblowing. The manager described an issue which had arisen which had been appropriately dealt with. However, another issue relating to restraint, had not been reported to the social services department, and advice was given as to the necessity for this. It is recommended that training regarding mistreatment of vulnerable adults and the need for protection is given to staff, to ensure that everyone is aware of principles and procedures. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 Residents benefit from living in a well maintained, clean and safe environment. EVIDENCE: Parts of the home checked during a tour of the premises were found to be clean, tidy and in a good state of decoration. Records of routine maintenance were in place. The grounds are well maintained and are safe, attractive and accessible to residents. Residents talked about their enjoyment of the grounds. The laundry is separate from both food storage and preparation areas and from resident lounges and bedrooms. Infection control procedures are in place to ensure soiled materials are appropriately handled. Washing machines are appropriate for purpose. One member of staff is employed to be responsible for laundry and for ensuring that residents clothes are properly labelled and sorted. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 Residents’ welfare is safeguarded by the numbers of staff on duty and the recruitment processes in the home. EVIDENCE: At the start of the inspection, an assessment of staffing levels was carried out: five carers were on duty, in addition to two cleaners, one laundry person, one cook and the manager. The manager uses the Department of Health Residential Forum guidance to establish what staffing levels should be, according to the dependency levels of residents. The rota shows five members of care staff on duty during the day and three members of care staff on waking duty during the night. Recruitment and personnel files showed that all relevant checks are carried out on employees, including Criminal record Bureau checks. Staff receive statements of terms and conditions. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 38 Residents benefit from the opportunity to comment on the way the home is run. The health, safety and welfare of residents and staff is mostly promoted and protected by procedures and practices in the home. EVIDENCE: A questionnaire is used in the home on a regular basis, to get the views of residents about the running of the home. Recent surveys showed positive results. Residents and families were given the opportunity by the home to comment during the inspection process. Staff meetings are held regularly to update any policies or procedures or feedback if changes are needed following complaints or inspections. Care staff receive supervision on an ongoing basis. The manager continually works to try and raise standards in the home, through individual supervision, staff meetings and notices to staff. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 20 Staff receive training in aspects relevant to the care of residents, such as moving and handling, food hygiene and infection control. Procedures are in place to ensure safe working practices. A complaint was received at the CSCI regarding infection control, related to protection from MRSA. The manager investigated and advised that procedures are in place in the home. However, one aspect of concern was noted during the inspection regarding protective clothing. Basic polythene gloves were being provided by the provider, which may not meet clinical guidelines and so may not adequately protect from cross-contamination. As a result, staff are purchasing their own gloves for use, which the provider cannot vouch for and which may not comply with safety requirements. Proper protective clothing must be provided for staff. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x x 3 x 2 Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 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 9 Regulation 13 Requirement Medication administered for residents must be appropriately signed for in records, in order to safeguard residents health and well-being Staff in the home must monitor more closely any behaviour of residents which may have a detrimental impact on other residents and take steps to ensure this does not happen. Staff must be provided with clinically recommended protective clothing to assist in prevention of crosscontamination when providing personal care for residents. Training should be provided to staff re correct use where a need is identified. Timescale for action 30th July 2005 2. 18 13 3. 38 13 Informatio n to be provided to CSCI by 30th July 2005 Evidence to be provided to CSCI by 30th July 2005 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 15 Good Practice Recommendations It is recommended that the manager re-introduces cooked C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 23 Clarendon Mews 2. 18 breakfasts as an option for residents, and provides choice for residents for afternoon refreshment It is recommended that training regarding mistreatment of vulnerable adults and the need for protection is given to staff, to ensure that everyone is aware of principles and procedures. 3. Clarendon Mews C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 24 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire 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 C51 S31736 Clarendon Mews V234797 290605.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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