Inspection on 19/07/05 for Claydon House

This inspection was carried out on 19th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Claydon House 16/11/07

Claydon House 03/05/06

Claydon House 06/01/06

Claydon House 02/03/05

Claydon House 28/09/04

Claydon House 26/02/04

Claydon House 30/09/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Claydon House 8 Wallands Crescent Lewes East Sussex BN7 2QT Lead Inspector Elizabeth Dudley Announced 19 July 2005 10:00am 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. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Claydon House Address 8 Wallands Crescent Lewes East Sussex BN7 2QT 01273 474844 01273 486175 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) Caring homes Limited Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (OP), 32 of places Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users accommodated must not exceed thirty-two (32). 2. Service users must be aged sixty-five (65) years or over on admission. Date of last inspection 2 March 2005 Brief Description of the Service: Claydon House is registered to provide personal care and assistance for up to 32 Older People and has been owned by Caring Homes Ltd since March 2000. The building consists of a detached Victorian house has been extended to provide accomodation over four floors. It is situated in a quiet private drive on the outskirts of Lewes. Lewes town centre is approximately hald a mile away and there is access to all main transport links and local amenities.There is limited parking space outside the home but unrestricted parking in surrounding roads, Wallands Park is within five minutes walking distance. Accomodation is comprised of mainly single rooms, with a shaft lift accessing all floors. There are two lounges and dining rooms and a conservatory which allows easy access to a well maintained garden. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 19th July 2005 over a period of eight and a half hours and is part of the annual inspection programme for this home. It was facilitated by the acting manager, Ms R Bekaert, the regulation manager Ms J Innes, and the regional manager Ms S Turner. Ms Bekaert commences the post of manager on 24th July 2005 and has been working at the home as support manager for the past month, the home has been under the management of the regional manager. During the day 19 residents and seven members of staff were spoken with, there were no visitors available at this time. Documentation including care plans, personnel files, financial details and health and safety records were examined and a tour of the home was undertaken. In general, comments received about the home from residents were positive, and they are looking forward to the home being under the permanent management of Miss Bekaert. Thanks are extended to the management, residents and staff for their help, courtesy and hospitality during the day. What the service does well: Claydon House is situated in a quiet, private drive and residents can socialise with residents from a neighbouring care home, they were seen sitting on chairs in the private driveway talking to each other and generally socialising. Residents spoke of the kindness of the staff and how helpful they were and staff spoken with appeared to be very fond of the residents and very concerned about their well being. The home provides very pleasant communal accommodation and has gardens which are well maintained and a large conservatory which is also used as an extra sitting area. The care of the residents is well set out in the care plans and local GPs hold a weekly surgery in the home. Residents stated that the food provided in the home by the regular cooks, was ‘lovely’ and said that they were very ‘well fed’. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 6 Residents are encouraged to make choices in their lifestyles and the new manager is planning to start an internet café in conjunction with a branch of Age Concern. What has improved since the last inspection? What they could do better: Staff and residents were still concerned about the lack of activities available and that there is a minibus but it is rarely used. There were minor maintenance issues that need attention and some of the rooms and corridors are in need of redecoration. Some residents stated that they had lockable doors and drawers but no keys, and one resident was concerned that she had to hook her door shut to maintain her privacy and was rightly concerned should she become ill. Some call bell points were not easily available to residents and some windows need window restrictors or risk assessments to ensure the safety of those who live in the home. Staff were concerned about the atmosphere in the home and felt that at times they had had issues which were not fairly resolved, they were worried that this had impacted on their care of the residents. Residents independently stated that they had been aware of problems in the home, but that these ‘ hadn’t affected the way we are treated’. However the regional manager has been aware of this and is in the process of putting this right, helped by the new manager. This will be monitored. Residents also stated that the quality of food was not so good when agency staff were employed, and it has been recommended that the manager checks this. Staff also said that ‘ the sandwiches made by the agency cooks are rough and fall apart and we have to redo them’. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 7 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. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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 Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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) 1,2,3,4,5. The home supplies sufficient information to ensure that prospective residents are able to make an informed choice when deciding whether to make Claydon House their home. EVIDENCE: The home provides a statement of purpose and service users guide which have been recently reviewed to reflect the changes within the home, and are written in a clear, easily read format, containing all the information as required by this standard. All residents have received a copy of the service users guide. On admission to the home residents receive a statement of terms and conditions, this is also presented in a clear and concise format and includes all the information as required by this standard. Prior to admission the manager visits all prospective residents to assess their needs, this information forms the basis of the care plan. This assessment takes place to ensure that the resident’s needs can be met, and to ensure that the prospective resident has sufficient information about the home. Prospective Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 10 residents and their representatives or relatives, are further encouraged to visit the home prior to admission, to meet the staff and other residents. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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) 7,8,9,10,11 Care plans contain sufficient information to enable the physical and medical needs of the residents to be met. There is a robust system of medication administration which ensures the safety of residents. However, the inclusion of social needs and residents background is required, to enable a balanced plan of care to be provided for residents. EVIDENCE: A sample of the care plans were examined and these were seen to have been reviewed on a monthly basis, to involve the resident or their representative in their compilation, and to address, in detail, the assessed physical needs of the resident. Care plans are in the process of being reorganised in order to facilitate their use and to ensure that residents needs are being fully met. Staff spoken with appeared to be conversant with the resident’s assessed needs and the care detailed in the plans. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 12 The home includes a biography of the resident in the care plans and this was not completed in one care plan that was examined, likewise the social needs were not always completed in some of the care plans. The home is supported by district nurses and GP’s who provide health care to the residents, the GP’s hold a surgery in the home once a week. A dentist and chiropodist visit the home and a community physiotherapist has been accessed. District nurses assess those residents who may have pressure damage and provide the necessary equipment to deal with this, although the home has some pressure relieving solid cell mattresses which are used as a preventative measure. Care assistants can accompany residents on hospital appointments if their relatives are not available to do so. Residents stated that they felt that they were treated with dignity and respect and it was noted that staff addressed residents by their preferred names rather than using forms of endearment which would not be appropriate. All medications were signed for on administration and although the home does not keep spare medication, stock control of creams and other items was seen to be undertaken. Only those care assistants who have undertaken medication administration training are permitted to give out the medications. One resident self medicates and it is recommended that this is reviewed at frequent intervals. Temperatures within the clinic room must be monitored and if over 25C then it is recommended a small fridge is provided to keep eye drops and creams within the required temperature parameters. It is also recommended that the home provides a controlled drugs cupboard as although there are no controlled drugs in the home at present, previously these have been stored in a locked box which is unsecured. The home has extended its policy on caring for the dying resident, and accesses the services of the Macmillan nurses and district nurses when this occurs. The acting manager stated that they prefer residents to stay in the home when very ill, unless medical needs dictate otherwise, and relatives and friends may stay with the resident. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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) 12,13,14,15. Residents are encouraged to make choices around their activities of daily living and the home has an open visiting policy. Social activities need to reflect residents interests and to be well planned in order to enhance the quality of residents lives. Agood standard of catering is normally available, this standard falls when the permanent catering staff are away, and dissatisfaction regarding this was voiced by residents. EVIDENCE: Residents are encouraged to exercise their choices in the activities of daily living and visitors are welcomed into the home at any time. Ministers of religion visit the home. The acting manager has liaised with another care home and hopes that socialisation between the two can take place. Some activities have been taking place facilitated by care staff, a limited activities programme being available. Although the management a minibus is now available for use for outings, care staff stated that this has not been used and that it was not available, and they also felt that the activities have been severely limited since the activities person left. Care staff were concerned that Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 14 residents were bored although they felt they had done as much as possible to alleviate this, this was confirmed by residents spoken with. Questionnaires received back by CSCI from residents and relatives also identified that the lack of activities were a problem. Comments such as ‘There is not much to do’, and ‘It’s alright if you are capable of amusing yourself’ were made. The previous activities co-ordinator is coming back to work at the home and therefore staff and residents anticipate that this will improve the type and amount of activities available. The acting manager has collected information on a number of activities suitable for residents of this age group and also intends to start an ‘Internet Café’ in conjunction with the local Age Concern society. The type of activities provided have been games, puzzles , some outings, musical entertainment and a coffee morning, however care staff felt that activities were infrequent and more was needed. The home also runs a trolley shop, but this has also been infrequent of late. The regulations state that residents past interests should be taken into consideration when planning activities and that these should be planned in conjunction with residents. The acting manager is very aware of the need to extend the range of activities and intends to do this once she is permanently in post. The cook has been in post for 15 years and is aware of all the likes and dislikes of the residents. There is a well balanced menu provided which allows choice of food at all meals, fresh fruit and homemade cakes are provided. There was a good supply of fresh, dried and frozen food and the kitchen was clean and well ordered. There is a cleaning rota but this should be signed for all cleaning undertaken. The cook stated that she is concerned that there was no form of ventilation in the storage area and the regional manager is seeking advice on this. All fridge and freezer temperatures were recorded daily and all hot food probed and records kept. Catering staff have their food hygiene course and although there is no evening cook, a person to do the evening washing up is employed. The home is still trying to employ an evening cook. The evening domestic should be in possession of a food hygiene or handlers certificate. Meals may be taken in two aesthetically pleasing dining rooms, and the resident may also be served meals in the privacy of their own room. It is recommended that a menu is displayed in the smaller dining room as well as the larger one. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 15 Residents stated that the quality and choice of food was very good and that there was ‘always plenty of food’. However they also stated that the second cook was on sick leave at present and that the food, especially suppers was not up to the standard expected when an agency cook comes in. Care staff also reiterated this, saying sandwiches made by the agency staff often have to be remade by the care staff. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Complaints are taken seriously and acted upon and care staff appear aware of their responsibility towards those within their care, therefore ensuring that residents can feel safe and protected within the home. EVIDENCE: The complaints policy is displayed on the notice board and is also included in the statement of purpose and service users guide, it meets this standard. Records are kept of complaints and one was received which was dealt with by the acting manager in a fair and competent manner. Care staff receive training on the protection of the vulnerable adult and appeared to understand their role in this. Residents can see financial advisors and solicitors in private and the home will help residents to access these services. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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) 19,20,21,22,23,24,25,26. Redecoration of individual rooms and minor maintenance and some window restrictors are required to be put in place to ensure that the home is pleasant and safe for residents. Residents privacy requires that door locks and lockable facilities are provided in some rooms. EVIDENCE: The standard of décor and maintenance is variable, communal areas are very pleasantly decorated and maintained, but some of the individual rooms and corridors will need to be redecorated in the near future. Refurbishment of the ground floor is planned, probably commencing late September 2005. Minor maintenance issues seen included the application of re-sealant and re-grouting of tiling in areas of the kitchen and over wash basins in some bathrooms. A plug requires fitting to the wash basin in the ground floor bathroom and a call system fitted in the first floor bathroom ( this was a requirement on the last inspection). One room had a very heavy fire door fitted, and the resident stated she had great difficulty opening it, other residents also commented on Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 18 the heaviness of some of the doors, and on opening these doors they were found to be quite heavy, especially for an older person. The lounges are comfortable and the large conservatory is used as a sitting area, which gives access to the garden. This was a very pleasant area, comfortably furnished and with plants creating an open feel. Residents were seen to be using this. The main lounge requires an extension to the call bell so that residents can reach this without having to stand and stretch over chairs, and the call bell in one of the bathrooms needs to be in close proximity to the w.c. Rooms that are occupied look comfortable and it is evident that residents can bring in their own possessions. Wiring from electrical equipment was seen to be stretching across the floor in some rooms. Some rooms still require to be provided with a lockable drawer or other locked facility to provide residents with a safe place for their possessions, one resident stated that although she has the lockable drawer she does not have a key to this, likewise she has not got a lockable door and she states that she prefers to have a door that locks. One double room was seen to have labels with the drawers labelled with residents names, although this room was unoccupied at present. This should be avoided as it creates an institutional atmosphere within a home. Two residents commented on the lovely views from their windows, these look across the garden and one said that ‘there was always something to watch’. Windows on the ground floor that have a large drop beneath them must be fitted with window restrictors, in some cases a risk assessment may be acceptable but management must assess those residents living around the individual rooms as well as the rooms occupant. Several fourth floor windows require window restrictors; the windows in the bathroom would be easily accessible by an agile resident. Water temperatures have been recorded on a monthly basis and are within recommended parameters. Most residents said they found their rooms comfortable although several identified the need for redecoration, two residents stated that the standard of cleaning in their rooms could be improved. One resident also said that some of the bed linen was becoming ‘thin’, but linen examined was in fair condition, but may need replacing in the near future. The home needs to be assessed by an occupational therapist or other suitably qualified person to determine whether there are sufficient aids and equipment and determine the homes suitability for its purpose. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 19 The standard of cleaning in the rooms was reasonable and that around the communal areas was good. A comprehensive range of infection control policies is available and staff stated that they were aware of these. Latest infection control research advises against bar soap being left in communal bathrooms and this should be removed, as should cotton towels. Hand washing equipment in the form of soap dispensers and paper towels were available in bathrooms. One resident voiced concern over the general cleanliness of one of the wc’s but the reason for this was discussed with the manager and it is obvious that staff are doing their utmost to deal with this. Staff said there were sufficient gloves and aprons available. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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 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) 27.28.29.30 Staff are employed in sufficient numbers to meet the needs of the residents and although few staff have NVQ 2, staff have attended various training to enable them to meet the needs of the residents. Recruitment practices are sufficiently robust to ensure residents safety. EVIDENCE: The home provides 3 carers in the morning and afternoons and two carers on a waking night duty. Staff stated that they felt there was enough staff to meet the needs of the residents. Previously there had been some concern voiced by staff over them having to get the supper as well as care for the residents. The regional manager stated that they are still trying to employ an evening cook and at present they are supplying an evening kitchen assistant to wash up. Residents stated that there always appear to be sufficient staff on duty and that attention to their needs is prompt and efficient. There is a senior carer working on all shifts. All staff undertake an induction course when commencing work at the home and this meets NTO guidelines. A new practical induction is being commenced to run alongside the present induction. There is a training matrix for all staff and individual training files were kept. Staff appear to undergo sufficient training to enable them to meet the needs of the residents within their care. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 21 A robust recruitment process is undertaken and all information as required by Regulation 19 and Schedule 2 was in place. The CRB checking process is adhered to. Few staff at present have undertaken NVQ2 and this is being made a priority. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 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 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) 31,32,33,35,36,37,38 The production of a new audit tool and resident questionaires, coupled with strong management should improve the ethos within the home for residents. Some health and safety matters need attention to ensure that residents are living in a safe environment. EVIDENCE: The acting manager is Miss Rachael Bekaert who commenced in post on 24th July 2005, she has been working at the home as a support manager since 31stMay 2005, and prior to this worked as deputy manager in another home owned by the company. Her previous experience includes many years at the Princess Grace Hospital in London as a senior sister in the orthopaedic department. Her qualifications are Registered General Nurse Level 1, B.Sc (hons) nursing and she is in possession of the Orthopaedic Nursing Certificate. She is studying for the Registered Manager award and is in the process of Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 23 completing this. Miss Bekaert intends to apply for registration with the CSCI in the near future. Staff and residents interviewed expressed concern about the ethos previously experienced in the home. Staff were very unhappy over this and stated that they were concerned it had affected the residents. They state that they now feel that things have improved and that during the time that Miss Bekaert has been involved in the home, there has been a very positive atmosphere. Both staff and residents spoke well of the new management structure and all stated that the change was beneficial. The regional manager is aware of the staff’s previous discomfort and has taken measures to address this and to make staff feel listened to. Plans were made to address the working atmosphere and this has been made a priority. Both staff and management voiced their awareness of the impact that a working atmosphere can have on residents. However most residents stated that they were very happy at the home, that the staff ‘are very good’ and ‘are quick to do what you ask them to do’. Residents receive questionnaires about life in the home and the results are collated and changes made in line with the results received, these are collated at the head office. Yearly audits take place and recently the regional manager has formatted a ‘self audit’ for the managers of the homes within the group which looks at all aspects within the home and will be used at Claydon House. This is seen as a positive step to improve both the quality of life for the residents and the environment within the home. The CSCI has not seen the business plan for the home, or audited accounts for the company for three years and therefore the regional manager has agreed to forward a copy of these to the CSCI Resident’s monies held for safe keeping are accounted for and a robust system of recording this is in place. The manager has not yet commenced staff supervision, although supervision was taking place under the previous manager. This will be recommenced as soon as the manager is settled in her new role. Regulation 26 visits have taken place but results of these were not forwarded to CSCI, but they were collected on the day spent at the home. It is expected that these will now be forwarded on a monthly basis. There is a comprehensive range of policies and procedures which have been updated on a regular basis and staff are aware of the content of these. All staff and residents records are kept in a locked office. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 24 All certificates relating to the servicing of utilities and equipment were in place and up to date, apart from the IEE certificate which will be forwarded to CSCI. All mandatory training has taken place and four members of staff have a first aid certificate. Automatic door closures have been put on some doors which residents wish to have open, and this must be reviewed as residents move into the home and if their needs dictate that these are required. Window restrictors need to be put in place and attention paid to the placing of electrical wiring for equipment. Copies of COSHH data should be kept with the substances to which it relates, it is recommended that copies are available in the kitchen. The fire door on the top floor requires some method applied to ensure that residents do not wander out of it and fall on the fire escape. It was seen that one of the rooms does not have a lockable door, and in order to give the resident security, a strong hook closure has been put on the inside of the door. The resident also expressed concern over this saying ‘ If I fall or am ill and the door is closed with the hook, no-one could get into me’. She is desirous of her privacy and also to prevent another resident is coming into her room and feels insecure if the door cannot be locked. This must be addressed. Likewise the difficulty experienced by some residents due to the heaviness of the doors must be addressed. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 25 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 1 3 2 2 2 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 1 4 x 3 2 3 2 Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 26 yes 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 12 Regulation Reg 16(m)(n) Requirement That a programme of activities is recommenced following consultation with service users regarding their needs and preferred interests. That a call bell in the first floor bathroom is installed, ( this was a previous requirement March 2005), that call bells in the lounge and top floor bathroom are easily reached by service users. That minor maintenance is undertaken That lockable drawers or cupboards and lockable doors are provided in all rooms, and services users provided with keys under the auspices of a risk assessment That the home is assessed by a suitably qualified person That the manager monitors the cleaning provided to service users rooms. That formal staff supervision takes place at times dictated by this standard. That window restrictors to the ground and top floor windows are either put in place or risk assessed. Timescale for action August 30th 2005 2. 19 Reg 23(2)(b)( d) (c) Sept 10th 2005 3. 24 Reg 12(4)(a) Aug 30th 2005 4. 5. 6. 7. 22 26 36 38 Reg 23(1)(a) Reg 23(2)(d) Reg 18 (2) Reg 13(4) Oct 30th 2005 Aug 30th 2005 August 30th 2005 Immediate Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 27 8. 9. 10. 38 38 38 Reg 13(4) Reg 13(4) Reg 23(4) That the hook is removed from the door of the service users room discussed at inspection That measures are taken to ensure service users safety with regard to the top floor fire door. That if future residents wish to have their doors kept open, suitable automatic door closures are provided. Immediate Immediate July 30th 2005 and ongoing 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. 4. 5. 6. 7. 8. 9. Refer to Standard 7 9 9 15 15 24 24 28 38 Good Practice Recommendations That care plans include the past life history of service users and their past and current social interests. That the self medication risk assessement is reviewed at more frequent intervals That a fridge for the clinic room is purchased, and if future needs dictate, a controlled drugs cupboard is obtained. That the manager monitors the standard of catering when agency catering staff are employed. That professional advice is sought regarding ventilation in the kitchen store room. That the weight of the doors in some service users rooms are assessed, and if possible, measures taken to facilitate service users using these doors. That labels are removed from drawers in service users rooms. Staff are encouraged to undertake NVQ 2 That COSHH data is kept with the substances to which it refers. Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 Claydon House H59-H10 S21410 Claydon House V226644 190705 Stage 4.doc Version 1.40 Page 29 - 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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