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Inspection on 31/01/08 for Claybourne Residential Home

Also see our care home review for Claybourne Residential Home for more information

This inspection was carried out on 31st January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Claybourne is a care home specialising in the care of older people with a dementia. The environment is deliberately designed to afford maximum opportunities for residents to wander freely and enjoy a high standard of comfort. A relative said, "They are very good at managing people with Dementia." Another said, "They are good at maintaining high standards of cleanliness and comfort for the residents." All prospective residents receive a comprehensive needs assessment before the service confirms it can offer a placement. A copy of the Statement of Purpose and Service user Guide is provided at the point confirmation.Relatives confirmed that the service strives to meet the social, occupational and spiritual needs of the residents at the home. The staff receive training and updates in all relevant areas and the organisation shows it`s commitment to it`s staff by providing incentives. The percentage of staff with a National Vocational Qualification is at 52%, above the minimum recommended. Throughout out this visit the manager demonstrated her wish to continually improve the service and to address any issues that had arisen through the inspection process.

What has improved since the last inspection?

A review of staffing levels since the last key inspection visit means that there are now sufficient staff deployed to meet the needs of residents. On going maintenance, refurbishment and redecoration mean that the majority of areas in the home are of a high standard, although there is a continuing programme. In the AQAA the manager has identified future plans and developments for the home.

What the care home could do better:

This service offers good quality outcomes in most areas, to ensure that residents receive the care they need. There are some areas that the home should develop further, these include ensuring that the Statement of Purpose and Service user Guide are up to date. The systems for the storage and recording of medication should be reviewed to ensure that residents can be confident that it is properly managed. Care records should contain all the information staff need to deliver appropriate care. Further work should be done to provide more activities in the home. It is recognising that the service is continually trying to improve in this area. Action should be taken to ensure that all areas of the home are free from offensive odour. The service should ensure that all staff have received training in recognising and reporting suspected abuse and all mandatory training is up to date.The manager should apply to us to be approved as the registered manager for the service.

CARE HOMES FOR OLDER PEOPLE Claybourne Residential Home Turnhurst Road Chell Stoke-on-trent Staffordshire ST6 6LA Lead Inspector Ms Wendy Jones Key Unannounced Inspection 31st January 2008 10:30 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 Claybourne Residential Home DS0000008219.V346476.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. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Claybourne Residential Home Address Turnhurst Road Chell Stoke-on-trent Staffordshire ST6 6LA 01782 790500 F/P 01782 832642 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) home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Zoe McCallum Care Home 45 Category(ies) of Dementia (45), Dementia - over 65 years of age registration, with number (45) of places Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 45 DE(E) Minimum age 50 years on admission The Care Manager achieves the Registered Managers award by 31 March 2006 11th October 2006 Date of last inspection Brief Description of the Service: Claybourne residential care home is a modern purpose built home, specialising in the care of older people who have a dementia. Opened in the autumn of 1997, the home is run by the Methodist Homes for the Aged, (MHA), which is a national voluntary organisation specialising in the care of older people. The ethos of the home is inspired by Christian values and is based upon providing a quality lifestyle for older people with dementia. Prospective residents do not have to be Methodist but can be from any religious denomination. The home is registered for 45 long stay residents with dementia, (DE(E)), and at the time of this unannounced inspection was occupied by 42 residents, of whom 1 was receiving respite care and 1 resident was in hospital. The design and specification of Claybourne provides a high standard of environment and facilities for people with a dementia. The accommodation is divided into three wings, each of which is equipped with a large lounge/diner/kitchen. An additional quiet lounge, bedrooms, bathrooms and toilets are also located in each wing. Centrally there is a large open plan sitting area, used for activities and entertainment and throughout accommodation is light, spacious and comfortable. Residents are able to move freely throughout the home and have easy access to the enclosed gardens that surround the entire property and which are a particularly positive feature of the design. Claybourne is situated in Chell, near Tunstall and is well located to access a wide range of local community facilities. Each prospective resident or their family receives a copy of the service user guide and contract identifying the costs and fees of the service at the point of admission. The weekly fees for the home at 09 April 2007 are recorded as £504. Other charges for day and respite care range from £26.25 to £36.05 per day. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was a key inspection site visit of this service undertaken on 31st January 2008 over a period of 9 hours and included formal feedback to the manager. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit have been acted upon; looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, staff, residents and a visitor were spoken to during the site visit and a brief tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of it’s performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives, staff and any professional that has involvement in the service. In total 6 relative, 1 resident, 1 advocate and 2 health professional surveys have been returned. The main points from these have been included in the main body of this report. What the service does well: Claybourne is a care home specialising in the care of older people with a dementia. The environment is deliberately designed to afford maximum opportunities for residents to wander freely and enjoy a high standard of comfort. A relative said, “They are very good at managing people with Dementia.” Another said, “They are good at maintaining high standards of cleanliness and comfort for the residents.” All prospective residents receive a comprehensive needs assessment before the service confirms it can offer a placement. A copy of the Statement of Purpose and Service user Guide is provided at the point confirmation. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 6 Relatives confirmed that the service strives to meet the social, occupational and spiritual needs of the residents at the home. The staff receive training and updates in all relevant areas and the organisation shows it’s commitment to it’s staff by providing incentives. The percentage of staff with a National Vocational Qualification is at 52 , above the minimum recommended. Throughout out this visit the manager demonstrated her wish to continually improve the service and to address any issues that had arisen through the inspection process. What has improved since the last inspection? What they could do better: This service offers good quality outcomes in most areas, to ensure that residents receive the care they need. There are some areas that the home should develop further, these include ensuring that the Statement of Purpose and Service user Guide are up to date. The systems for the storage and recording of medication should be reviewed to ensure that residents can be confident that it is properly managed. Care records should contain all the information staff need to deliver appropriate care. Further work should be done to provide more activities in the home. It is recognising that the service is continually trying to improve in this area. Action should be taken to ensure that all areas of the home are free from offensive odour. The service should ensure that all staff have received training in recognising and reporting suspected abuse and all mandatory training is up to date. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 7 The manager should apply to us to be approved as the registered manager for the service. 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. Claybourne Residential Home DS0000008219.V346476.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 Claybourne Residential Home DS0000008219.V346476.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): 1, 2, 3, 4 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 may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The organisation has produced both a Statement of Purpose and Service user guide, in addition to a breakdown of the costs and fees the service charges. The manager confirmed that each service user or their family receive a copy of these at the point of admission. It is important that these documents are reviewed regularly to ensure that they are up to date as some of the information in them wasn’t. The service has well established assessment procedures, which ensure that nobody is admitted to the home without their needs being fully assessed and they receive confirmation that the service can meet them. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 10 A relative confirmed that she had the opportunity to visit the home before her relative accepted the placement and stated that she had received information about the service. Another said, “ this care home provides the most appropriate service we could find having visited 10 homes previously.” Two relatives commented on the costs of the service, one said, “ I am obviously concerned about the weekly cost of providing suitable and acceptable care for my mother, without realistic support from Social Services.” “ My relatives life savings will be swallowed up in paying for her own dementia care. She received no financial help.” This issue is outside of the remit of the inspection site visit and was not discussed with the manager at the time, but the subject of funding and cost is an issue that is raised often. This service does not offer intermediate care. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their health and personal care is based on their individual needs and the principles of respect, dignity and privacy are put into practice. But cannot be sure that the systems for the safe storage and recording of medication are robust; this potentially places them at risk. EVIDENCE: Throughout this site visit staff were observed to be sensitive in their approach to residents, treating them with respect and affording them their rights to privacy and dignity as the occasion arises. There is evidence of good relationships between staff and service users, and a relative confirmed that this has also been her observation during her visits to the home. A random sample of 4 care records were seen during this visit to assess if the staff have sufficient information to meet the care needs of residents. The service is in the process of introducing a new care plan format that follows a “person centred model,” this is clearly an improvement on the previous format Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 12 and the quality of information is of a high standard generally. Each care file has a personal profile that includes an assessment of the needs and wishes of the individual. Care plans are developed from these assessments and are subject to regular review. Information about likes and dislikes, preference for a bedroom door key or receiving care from a male or female carer, rising and retiring times, food preferences, allergies and spiritual needs are included in this information. Families are also asked at some point if they have plans in place in the event their relative passes away, this information is also recorded. There was a concern about the care records of one service user where the quality of information was markedly lower than the other files seen. The manager agreed to look into the matter and has since confirmed that the records were not complete, this has now been rectified. There is evidence in some of the files that relatives have been included in the development of care plans. Health monitoring records are also in place, for example, weight and nutrition. In some instances the records of nutritional and fluid intake are not fully completed giving an inaccurate or misleading account of the person’s intake during the day. This was discussed with the manager; advice was given on how this could be remedied and the importance of maintaining accurate records when a particular issue had been identified. The manager has since confirmed that action has been taken to remedy this. One resident returned a survey and was supported to complete it by their relative, they raised an issue regarding having to pay for private chiropody because the health service chiropodist did not visit frequently enough to meet her needs. This is out side of the remit of the inspection, but the manager may be able to pursue this matter on the resident behalf. Feedback from relatives included comments such as, “Generally my relatives needs are met, although shaving is not always attended too. Basic care is so important as it gives the resident their dignity and means so much to their relative.” “ The staff are always caring and patient.” “ Residents are always treated with dignity and respect.” “ More regular toileting and better communication between care staff and senior staff.” Medication management is generally to a good standard, staff have received medication training and the manager discussed how staff are also been assessed to ensure competence. Matters arising, that were discussed during this visit include a concern around the administration of medication to one resident receiving respite care, the inappropriate temporary storage of the mobile medication trolleys and on some occasion’s evidence that medication had not been signed for. In addition the manager was advised that if residents are prescribed “as required” or irregular medication, the instructions for administration should be clear. This was not the case in two examples. Also Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 13 where regular medication is prescribed staff should record the reasons it is not given, if this occurs. For all of these matters the manager has since confirmed that she has taken action to address them and has made changes to ensure that they don’t occur again. None of the current resident group self medicates Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 14 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 (good). This judgement has been made using available evidence including a visit to this service. People who use services are not always able to make informed choices about their life style, but their needs and wishes are known to the staff team and efforts are made to ensure that their social, spiritual, cultural and recreational activity needs are met. EVIDENCE: The records show that every effort is made to establish residents preferred social and recreational choices at the time of assessment, and efforts to meet these needs are made. The service also has a group of volunteers who regularly visit the home to offer support with various aspects, including practical assistance with repairing clothing and sewing name tags on clothes or support to provide residents with more opportunities to engage in activities. In relative survey’s comments included, “more activities in smaller groups would be of benefit.” One relative said that the residents would benefit from a residents forum, this has been suggested to the manager. The home produces a good quality monthly newsletter, which details planned events and other news of interest, this is available to residents and visitors and Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 15 in some instances the newsletter is sent out to families. Posters advertising activities are also on display in each of the living areas and in the main entrance of the home. Comments in relative survey’s included, “The home provides emotional and practical support for residents and their family, and residents choices are supported whenever practicable.” “My relative and other residents would be more stimulated if they could be in very small groups when activities are arranged.” “They ensure individuality by not being prescriptive at mealtimes.” “They promote a very happy atmosphere.” “ More activities could be done, although compared to other residential and nursing homes it is quite good.” The service has a Methodist chaplain who visits the home weekly. Residents of other faiths are able to receive the spiritual support they choose. The manager gave examples where the differing spiritual needs of residents are respected. The organisation has confirmed in the AQAA their commitment to ensure that they operate to ensure that the diverse needs of residents are respected and met. Two mealtimes were observed during this visit, both were relaxed and unhurried and staff were attentive to the needs of residents. Tables were nicely set and condiments are available. Those residents requiring assistance with their meal are given one to one attention. A hot cooked meal and sweet is provided at lunchtime and residents are given a choice of two alternatives. During the evening a hot or cold choice is offered, at all mealtimes’ alternatives to the main menu choices can be provided on request. For those residents requiring a pureed diet, each food item is pureed and presented separately ensuring the individual resident is able to see what they are being served and taste the individual flavours of the food. All residents who were consulted, along with visitors to the home, confirmed that the quality and variety of food is of a high standard. The cook discussed proposals to offer a choice of cooked breakfast in the future. Currently care staff provide a choice of cereals and toast, although some residents do choose to have alternatives such as egg or tomatoes on toast. Claybourne Residential Home DS0000008219.V346476.R01.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 (good). This judgement has been made using available evidence including a visit to this service. People who use the service or their supporters are able to express their concerns and have access to a robust, effective complaints procedure. This means they can be sure that they will be listened to and protected from abuse. EVIDENCE: The service has a complaints procedure in place copies are on display in the home. Of the 6 relative survey’s returned, 4 said they knew how to make a complaint, 1 said they didn’t know and 1 said they weren’t sure. A relative spoken to during this visit confirmed that she felt able to go to the manager or staff team with any concerns she may have and gave examples of how things raised in the past had been addressed satisfactorily. We haven’t received any complaints about this service. It was noted during this site visit that there were many thank you cards, letters and notes from satisfied relatives of residents on display in the home. Relatives comments in surveys have included, “They deal with any problems quickly and in a caring manner.” “ After raising a concern it would be useful if a senior member of staff would check with the relative after a period of time to see if the problem has improved.” Another relative said, “ I have had two items of furniture belonging to my relative go missing, with no real effort to find them by the staff when they were reported missing.” This comment wasn’t shared with the manager during the site visit, but has been discussed with her since the visit. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 17 We are aware that a vulnerable adult referral was made to the local authority in January 2007, after some investigation the allegations were reported to be unfounded. The training records provided by the service show there are gaps in some areas of training around the safe guarding of vulnerable adults and recognising and reporting abuse. The manager agreed to look at this area. She has since confirmed that all staff will have access to this training. Claybourne Residential Home DS0000008219.V346476.R01.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, 20, 25 and 26. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the physical design and layout of the home enables them to live in a safe, comfortable environment, that is clean, generally well maintained and which encourages independence. EVIDENCE: Claybourne provides an accessible and safe environment that meets the needs of residents. There is a rolling programme of decoration and maintenance intended to ensure high standards throughout. Although Claybourne is a large home, its design, which consists of 3 separate living areas leading from a large central recreational area, ensures that it retains a homely appearance. Residents were observed to move freely throughout the home. During this site visit there was evidence that the service has a problem with an unpleasant odour in one area of the home. The manager stated that they had tried a number of things to eliminate the problem and had some success but Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 19 the problem had continued. There was discussion during the visit about what else could be tried and following the inspection the manager has reported the action taken to try to resolve this matter. The three units named Churchill, Wedgwood and Doulton are almost identical in style and design. Each accommodates 15 residents; all provide single bedrooms with en-suite. Each bedroom door has its own lock, number and letter box and to the side of each door are photographs of the occupant to help residents to find their own room. Each unit has a spacious lounge /dining room with smaller kitchen area, one relative survey suggested that staff would benefit from a dishwasher in these areas. This wasn’t discussed during this visit. In addition the units have another lounge, these are generally not much used by residents, one was observed to be used as storage for the handyman while he is redecorating bedrooms, another as a staff meeting /training room and the third as a family room where residents who had visiting relatives could meet in some privacy. The manager stated that she is trying to think of ways to ensure theses areas are better utilised for the benefit of residents. The main kitchen and laundry are both well-equipped areas with their own dedicated staff teams. These along with office space, the staff room and a small flat for relatives or visitors are provided in a fourth wing of the building. The home has extensive grounds and sufficient parking space; these areas were not included in this inspection site visit. Claybourne Residential Home DS0000008219.V346476.R01.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 (good). This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their care needs are met by a staff team who have the skills and knowledge to meet them and who are provided in sufficient numbers. EVIDENCE: At the last key inspection concerns about staffing levels had been raised, but since then this has been remedied and levels are now more acceptable. The manager stated if needed to she can bring in extra staff to ensure that residents social and care needs are properly met. The total care staffing numbers for the day of this visit equated to 10 during the morning and 9 in the afternoon and evening and four during the waking night. In addition to this there was the manager, her deputy and two senior staff. Catering staff included 1 from 9am-17.30, 1 from 9am-15.00 and 1 from 17.00-19.00. There were two laundry staff and additional domestic hours as well as administration hours. The activities co-ordinator is currently not at work and the maintenance person is on holiday. Relative comments in the survey’s included, “ I feel that residents would benefit from more one to one contact, but understand that there are not always the resources for this to be possible.” Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 21 Recruitment records show that staff have proper checks carried out including CRB, written references and evidence of employment history, a sample of 5 files show that all had application forms, job descriptions and contracts of employment. It was not established during this visit what checks are carried out for volunteers, this should be confirmed. A staff training matrix shows that the numbers of staff trained to NVQ level 2 is good and the service aims to further increase this number. A number of innovations have been introduced to provide incentives to staff, including long service awards and rewards for good time keeping. In addition a variety of new training methods have been introduced to support staff to with their training needs since the last key inspection. Claybourne Residential Home DS0000008219.V346476.R01.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. People who use the service can be confident that it operates to a good standard, that their health and safety is assured. There is evidence to suggest that the service is continually striving to improve. This should give them confidence that the service can meet their needs. But the manager has not yet been approved by us and has yet to complete the manager award. EVIDENCE: The manager has been in post since the 1st March 2007, she is a qualified nurse, RMN and is reported to have many years experience in the healthcare sector. As yet she has not applied to us to be registered but knows she must do so and she has yet to complete the Registered Care managers Award. The evidence from this inspection was of a manager who appeared to have a good understanding of her role. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 23 A relative said, “as well as supporting my relative the manager and carers at Claybourne always have time for us and are there to support us whenever we need them.” Information in the AQAA indicates that all equipment in the home is maintained and serviced regularly. Fire safety records are properly maintained and fire risk assessments have been carried out. Staff have attended fire drills and fire training. A check of the certificate for registration shows that this is not accurate, as it has the previous managers name on it, this will be addressed with the organisation separately. A sample of financial records show that they are well organised and provide evidence of every transaction made on behalf of the individual. Due to the vulnerability of residents their personal allowance is managed on their behalf either by the service or relatives. It was not clear if each resident’s capacity to consent, or their ability to manage their own money has been assessed. A volunteer who helps to manage an account used to provide residents with activities, provides additional input. The administrator reported that the manager undertakes ad-hoc checks on the financial records. A bi annual audit is carried out by head office and as all records are computerized they also monitor balances. A sample of staff records shows that staff are receiving one to one supervision sessions. The minimum frequency recommended is 6 times per year. The organisation has systems in place for monitoring and auditing the quality of the service provided and produces action plans for the manager to follow based upon the outcomes of these audits. A representative of the organisation makes monthly monitoring visits to the home, copies of the reports from these visits are available in the home and were provided during the visit. Claybourne Residential Home DS0000008219.V346476.R01.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 3 3 4 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x x x 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 x x 3 Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement The registered provider must ensure that the standards for the management of medication are improved by ensuring the staff sign the MAR sheets on every occasion. The registered provider must ensure that the arrangements for the storage of medication are improved by ensuring that the mobile medication trolleys are secured when not in use. Timescale for action 29/02/08 2. OP9 13 29/02/08 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 OP1 OP7 OP9 Good Practice Recommendations The Statement of Purpose and service user Guide should be reviewed to ensure they are up to date. The service should ensure that care plans contain all relevant information to enable staff to provide the care required for each individual. The service should ensure that the instructions for DS0000008219.V346476.R01.S.doc Version 5.2 Page 26 Claybourne Residential Home 4 5 6 7 OP9 OP22 OP26 OP31 administering as required medication are recorded. The service should ensure that a reason why medication is not given is recorded. The service should be more proactive in it’s use of communal space for the benefit of residents. The service should ensure that all areas of the home are kept free from offensive odours. The manager should apply to us to be approved as the registered manager and complete the Registered manager s award or equivalent. Claybourne Residential Home DS0000008219.V346476.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Claybourne Residential Home DS0000008219.V346476.R01.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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