Inspection on 13/06/05 for Clements House

This inspection was carried out on 13th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clements House 20/09/06

Clements House 19/12/05

Clements House 14/01/05

Clements House 12/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Clements House 36 Fish Lane Bognor Regis West Sussex PO21 3AH Lead Inspector Jo Hartley Announced 13 June 2005, 09:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clements House Address 36 Fish Lane, Bognor Regis, West Sussex, PO21 3AH 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) 01243 868776 Allied Care (Mental Health) Ltd Mrs Sandra Lavinia Pudduck Care Home (CRH) 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD), (7) of places Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Only Service Users under the age of 65 years may be admitted Date of last inspection 14 January 2005 Brief Description of the Service: Clements House is a detached two storey care establishment in a residential area in the village of Aldwick, close to the coastal town of Bognor Regis, West Sussex. The property faces a busy main road but large gates provide seclusion. Parking is available on the road outside. The front of the property provides a courtyard with hanging baskets, and there is a secluded rear garden with a decked area and a pond. The establishment provides care for up to seven persons with mental disorder. Each person has their own room with ensuite, and there are shared facilities of a large lounge/dining room and conservatory. The registered persons are Allied Care (Mental Health) Ltd and the responsible individual is Mr Aslam Dahya. The registered manager is Mrs Sandra Puddock. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was carried out over a period of three and quarter hours. The inspector also read and took into account information held on the service file since the last inspection in December 2004, and read the previous two inspection reports. During the inspection the inspector spoke to two service users and two members of staff. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective service users’ needs and aspirations are assessed prior to admission. EVIDENCE: Four service users’ files were examined during the inspection. All files had evidence that service users’ needs and aspirations had been assessed prior to admission. Care Programme Approach assessments were seen on all files. Every file examined had an individual Service User Plan drawn up from preassessment information. Reasons for restrictions on choice and freedom were clearly stated and signed by the service users concerned. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Service users know their needs are reflected in their individual plan. They are enabled to make decisions about their lives with appropriate assistance. They are also supported to take risks. EVIDENCE: Service users’ files seen during the inspection were clearly set out. They included individual care plans, risk assessments and information on any restrictions in freedom and choice. One service user spoken to say he feels that he is involved in decisions that are made about his life as staff discusses things openly with him. The manager said every resident has a keyworker, and the two residents spoken to confirmed this. Records seen showed that some residents control their own finances; others either have an appointee that is either the manager or a relative. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 16, 17 Service users are able to take part in appropriate activities, and are encouraged and supported in being part of the local community. Their rights are respected and responsibilities recognised in their daily lives. Meals provided are healthy and enjoyed by service users. EVIDENCE: On the day of the inspection one service user was working voluntarily in a charity shop. During the inspection another service user went into town to do some shopping. One service user said that he had been attending college until recently but now has left. He said that he goes to the gym regularly with another service user. Keyworkers prompt and help individuals with independent living skills. A list of planned activities was seen; the manager said that the residents choose activities. A resident said that he received a polling card for the recent general election, but chose not to vote. Staff were witnessed asking permission from residents before entering their bedrooms. Bedrooms were seen to have locks. Residents hold keys to their rooms. A menu seen provided a nutritious and balanced diet. A service user said “the food is lovely”, he chooses not to eat pork or beef and the home Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 10 provides an alternative for him. Care plans inspected monitored the weight and dietary requirements of the service users. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 Service users’ physical and emotional health needs are met. EVIDENCE: Care plans examined during the inspection clearly recorded residents’ physical and emotion health needs. Records of medical appointments, treatments and accidents are recorded in a health section of service users files. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Service users felt that their views were listened to. The home has policies and procedures in place to help protect service users from abuse, neglect and selfharm. EVIDENCE: Policies and procedures on complaints, abuse and whistle blowing were inspected. They were all found to be adequate. The complaints book was examined. One complaint had been recorded since the last inspection. The record shows that the complaint had been responded to within the required time scale. Service users said that they talked to the manager or their key worker if they have any concerns. They also said that a house meeting is held every month, at which they are able to raise any concerns or worries that they may have. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Service users live in a homely, comfortable and safe environment, which is clean and hygienic. EVIDENCE: A tour of the home showed it to be clean, hygienic and free from offensive odours. The decoration was in good order. Furnishings were comfortable and domestic in character. On the day of the inspection the suite in the lounge was covered with assorted throws, as the suite was due to be re-covered. The inspector was told that the new covers had been ordered. The gardens were seen to be well maintained. The rear garden has a decked area, a pond and seating. One wall in the rear garden has a mural painted by one of the residents. The home’s maintenance book was seen. Staff enters maintenance requests, which are then signed off by the home’s maintenance man when they are completed. A director of the company inspects the home for major maintenance requirements yearly and makes a maintenance plan for the year. Major work is completed by contractors. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 36 Appropriately trained staff meets service users’ individual and joint needs. Service users benefit from well-supported and supervised staff. EVIDENCE: Records for four members of staff were examined. These showed that staff has received training on various health and safety courses including Food Hygiene, Infection Control, Fire Training, First Aid and the Management of Medication. Training had also been provided in Mental Health and Adult Protection. Staff spoken to say the company provides lots of training. One member of staff said that he finds the training helpful and timely. Records show, and staff confirm, that all new staff receive induction training. Both members of staff said they have supervision every month with the manager. One member of staff said he finds supervision very useful for developing his practice and career. Staff stated that team meetings are held approximately every month. Staff is able to add items to the agenda. The company provides a counsellor who visits the home every week to provide support to staff. A member of staff said he finds the manager “…very supportive, that she always listens and judges fairly.” Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health, safety and welfare of service users are promoted and protected. EVIDENCE: Staff training records show that staff has received training in Health and Safety. Comprehensive risk assessments were seen for health and safety issues within the home. Individual health and safety risk assessments were seen for every service user. Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clements House Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 17 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 Good Practice Recommendations Clements House H60-H11 S48441 Clements House V224086 130605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor, Ridgeworth House, Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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