Inspection on 15/02/06 for Clayfield

This inspection was carried out on 15th February 2006.

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

Clayfield 07/09/06

Clayfield 30/11/05

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Clayfield Clayfield 3-4 Clayfield Villas Victoria Road Barnstaple Devon EX32 8NP Lead Inspector Andy Towse Unannounced Inspection 15th February 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 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. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clayfield Address Clayfield 3-4 Clayfield Villas Victoria Road Barnstaple Devon EX32 8NP 01271 374066 01271 374066 clayfield@piltonia.supanet.com 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) Mrs Lynette Sylvia Hollick Mr Antony John Hollick Mrs Lynette Sylvia Hollick Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (12) Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Clayfield comprises two former Victorian houses which have been converted into one residence. The resulting home offers spacious accommodation which is well maintained. Externally the property has a front garden extending to the main road and at the rear an enclosed, easily assessable and pleasant courtyard area. The home is situated within easy reach of the resources of Barnstaple. Clayfield is registered to accommodate up to 12 older adults who may also have dementia or mental health problems. The accommodation is on two floors which can be accessed by either stairs or the stair lift. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over a period of six hours. Information contained in this report was gathered through discussion with the registered manager, discussion with individual residents, inspection of documents and policies within the home, including care plans. As stated in the previous report of 30th. November 2005, the present owners have only recently purchased the home and are introducing some changes, such as more effective care planning, a key worker system and training whilst still maintaining the welcoming and friendly atmosphere which was apparent at previous inspections. The CSCI Pharmacist, Brian Brown was also present during part of the inspection and compiled the section of this report relating to medication storage, recording and dispensing. What the service does well: What has improved since the last inspection? What they could do better: It is recommended that the home regularly audit the medication administration records and that hand transcribed records are double signed. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 6 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. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None The core standards were inspected during the previous inspection of 30th. November 2005. EVIDENCE: Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 9 All medication is stored securely and the new owner is putting systems into place to ensure the safe handling and administration of medicines in the home. EVIDENCE: Service users following a risk assessment process are supported to look after their own medication where appropriate. The quantity of medication received monthly is recorded and signed. However no record is made of the date of this receipt. For medication received at other times then no record of receipt is made. The new owner is in the process of developing a new medication handling and administration policy Recent photographs are available to enable the positive identification of service users prior to medicine administration taking place. Hand written entries are made on the Medication Administration Record (MAR) charts but they are not signed and dated by the person making the entry and another person does also not check them. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 13 Clayfield is proactive in encouraging the involvement of relatives in the home and in maintaining contact with family and friends. EVIDENCE: Clayfield operates an ‘Open Visiting Policy’ which is referred to in its Statement of Purpose. This states that it ‘is possible to visit residents at any time of day or night’, although it advises that it is advisable to check with the person in charge prior to arranging ‘out of hour’ visiting in order to check that the resident is awake and prepared to receive visitors. Residents who wish can fund the installation of a landline to their bedroom, but otherwise can use the extension to the home’s telephone system. They can also communicate using the home’s email facility. In order to facilitate communication with friends and relatives staff are available to assist with letter writing or reading. To ensure privacy all personal mail is delivered to residents unopened on the day of its arrival. Ongoing contact with relatives was evident on the day of the inspection when three residents had received visitors in person and another had had contact by telephone with a friend or relative. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 11 A resident spoken to spoke about having ‘lots of visitors’ and that manager had made it clear that this was the resident’s home. The same resident stated that Clayfield ‘feels like home.’ The home is also setting up relatives meetings to encourage the relatives of residents to become more involved with the running of the home and the development of the service. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18 The home’s comprehensive training programme safeguards residents from abuse. EVIDENCE: As stated in the previous report, Clayfield has an appropriate complaints procedure. Since the last inspection the registered manager has arranged training on the subject of the Protection of Vulnerable Adults. This training used the Edexcel training programme of which the registered manager is a member. The manager led the training. The training is comprehensive and includes questionnaires which staff, having completed the training were in the process of compiling and returning to the registered manager. This would allow her to assess the level to which staff had understood the issues raised by the training and therefore their awareness of issues relating to protecting vulnerable adults from abuse. In addition to the above the home also has copies of the ‘Alerter’s guide’ and other documentation provided by Social services relating to the Protection of vulnerable Adults. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 25, 26 Clayfield offers its residents a clean, well maintained and safe environment which is domestic in style. EVIDENCE: In the last inspection it was recorded that radiators and pipes had not been safety guarded. Since that inspection the owners have conducted risk assessments into which residents are most at risk and are currently instituting a programme of safety guarding radiators and pipework starting in the rooms where residents have been assessed as being most at risk. Whilst the core standards in this section were inspected as part of the last inspection and therefore did not constitute part of this inspection, it should be recorded that the home has a good standard of hygiene and cleanliness and that infection control procedures were seen to be being adhered to. The home offers its residents a domestic style of accommodation and has homely touches that reflect this and add quality to residents’ lives. An example Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 14 of this being fresh flowers on every dining table with matching napkins and table cloths. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Residents’ care is assured by staffing levels appropriate to the assessed needs of residents combined with staff receiving appropriate training. EVIDENCE: The new owners have retained most of the staff who were employed when they took over the home and have added an additional wakeful night care assistant as they considered this staffing increase to be in the interests of the safety and wellbeing of residents. There are two staff on in the evenings and afternoon and three on in the morning. The manager’s hours are in addition to the care staff hours. On the day of the inspection this level of staffing appeared appropriate to the needs of residents. The home operates a robust recruitment procedure which ensures that no staff work unsupervised until the home has received appropriate police checks. The registered manager is aware that the induction programme which they inherited was not up to the standard expected by Skills for Care (formerly TOPSS). The registered manager showed evidence, by reference to her schedule, that she was intending introducing a new and improved induction programme which would meet the needs of staff. The manager is introducing more training into the home. This is via training days, as with that relating to Vulnerable Adults, and also through handouts covering topics such as the role of the key worker, the principle of good record keeping, and information regarding Health and Safety issues, which are given Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 16 out with wage packets. In addition the manager is encouraging staff to attend NVQ courses and is discussing NVQ training with the local college. To facilitate NVQ training at the home the manager is assessing three students and will become an NVQ assessor. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 38 Staff at Clayfield benefit from the management’s open, positive and inclusive style, which allows for staff development and resident involvement, whilst retaining a safe environment. EVIDENCE: The manager is currently encouraging staff to be more involved in the running of the home. One way in which she is doing this is by giving staff special responsibilities relating to thing such as Health and Safety, liaising with relatives, and compiling medication profiles. She is also increasing the involvement of relatives of residents in the running of the home by inviting them to a specially convened meeting which will take place at the weekend. At this meeting, amongst other agenda items will be a discussion of the response by residents to a recently submitted quality assurance questionnaire. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 18 The registered manager is aware of some of the shortcomings in the service which she inherited. She has developed a business plan to address these. Work to be done is prioritised in relation to the safety and well being of residents. The inspector was informed that at the time of purchase in September 2005 issues such as the safety of gas and electrical appliances and installations and fire safety equipment had been ascertained, although at the time of the inspection no recent evidence relating to gas and electric appliances was available. Records showed that staff received training which was relevant to the safety of residents. This included Moving and Handling training using an external trainer which had been booked for February and March 2006 and fire safety training. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X x X X X X X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X X X 3 Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 9 Good Practice Recommendations 1 It is recommended that when hand-transcribed entries are made, these be written, signed and dated by the first person and then checked and signed by a second person. 2 It is recommended that the date of receipt of all medicines be recorded on the Medication Administration Record (MAR) chart along with quantity received and the signature or initials of the person making the entry. 3 It is recommended that all staff be trained on the contents of the new medication policy when developed. 4 It is recommended that the MAR charts be audited regularly to identify any shortfalls in recording and that a record be made of these audits and the actions taken as a result. Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Clayfield DS0000065556.V283068.R01.S.doc Version 5.1 Page 22 - 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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