Inspection on 31/08/06 for Clemsfold House

This inspection was carried out on 31st August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clemsfold House 24/11/09

Clemsfold House 29/09/09

Clemsfold House 22/06/09

Clemsfold House 01/11/07

Clemsfold House 08/11/05

Clemsfold House 07/06/05

Clemsfold House 05/10/04

Clemsfold House 25/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Clemsfold House Guildford Road Broadbridge Heath Horsham West Sussex RH12 3PW Lead Inspector Ms A Campbell-Currie Unannounced Inspection 31st August 2006 10:00 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 Clemsfold House DS0000014459.V310372.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. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clemsfold House Address Guildford Road Broadbridge Heath Horsham West Sussex RH12 3PW 01403 790312 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) clemsforldhouse@sussexhealthcare.org Dr Shafik Hussien Sachedina Mr Shiraz Boghani Doreen Rebecca Farrelly Care Home 48 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (48), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (48) Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Forty eight (48) persons in the category Dementia Elderly (DE) (E). Forty eight (48) services users in total may be accommodated. To include up to eight (8) persons in the category Dementia (DE) over the age of Forty (40) to sixty five (65) years. To include up to forty eight (48) persons in the category Mental Disorder Elderly (MD) (E). No further service users in the category old age not falling within any other category (OP) will be admitted. Current service users in the category old age not falling within any other category (OP) may continue to be accommodated. 8th November 2005 Date of last inspection Brief Description of the Service: Clemsfold House is registered to provide personal care for up to forty-eight people. Registration categories allow for forty-eight people who have dementia (DE)(E) and mental disorder (MD)(E) over sixty-five years of age. This includes up to eight service users in the category (DE) over the age of forty and under sixty-five years. Current service users over the age of sixty-five not falling within any other may still be accommodated but no others in this category may be admitted. Clemsfold House is a detached well-maintained property situated in a rural area about three miles from Horsham. It has a well-maintained, accessible garden. Dr S Sachedina and Mr S Boghani privately own the service. Mrs D Farrelly is the registered manager responsible for the day-to-day running of the home. The weekly fees for the home range from £475 to £625 for an en-suite single room. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit to Clemsfold House was a part of the Key Inspection of the service. The registered manager was on leave; the two deputy managers were on duty and both assisted with the inspection. There were thirty-eight people accommodated in the home. A partial tour of the building took place, time was spent sitting with a number of service users and eight people were spoken with. There were no relatives available for discussion. Five members of staff were spoken with including the chef who was on duty. A GP was visiting service users and provided feedback about the care people receive. Samples of case records and other relevant documents were also read. A meeting had been held with Senior Managers from Sussex Health Care as part of the preparation for the inspection. The hairdresser was visiting the home during the day. A member of the cleaning staff was doing work for the NVQ award during the day. On this occasion the outcomes for service users living at Clemsfold House were assessed in relation to the key National Minimum Standards. The requirements that were made at the previous inspection were also monitored. The judgements have been made from evidence gathered during the inspection, which includes a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? The area outside the front of the building has been improved so that people have a pleasant place to sit and enjoy the fresh air. New flooring has been laid in one of the lounges and several rooms have been decorated. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 6 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. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 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 Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 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): 3 and 6 Quality in this outcome area is good. Service users have a thoroughly assessed before they move to the home to ensure that their needs could be met. Intermediate care is not provided at Clemsfold House. EVIDENCE: Samples of case records were read and showed that a thorough assessment of need had been carried out before people moved to Clemsfold House. The assessments included information gathered from relatives and health and social care professionals. Information included some details about the person’s social history, interests and life experiences. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 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): 7, 8, 9 and 10 Quality in this outcome area is good. Service users’ health, personal and social care needs are set out in an individual plan of care. Peoples’ health care needs are fully met. The policies and practice regarding medication ensures the protection of service users. People feel that they are treated with care, sensitivity and respect. EVIDENCE: Samples of case records that were seen showed that an individual plan of care had been drawn up. Not all records seen had a photograph of the service user attached. The care plans included details of health and personal care needs with guidance to staff about the way that care should be provided. It was not clear in all cases that issues relating to the person’s emotional and mental health needs had been noted to ensure that staff understand how to ensure people are supported in these areas of their lives. Risk assessments had been carried however the guidance to staff was not clear in all cases seen. One care plan had been drawn up with a person-centred approach. It was evident that peoples’ care plans had been reviewed. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 10 The records seen showed that peoples’ health care needs are being met. A GP and a psychiatrist who specialises in the care of older people both visit the home on a regular basis. The GP was visiting during the afternoon and people were being seen in private. The GP said that there is very good communication with the home and this ensures that peoples’ health needs are being monitored and addressed. The deputy managers also said that there is an excellent relationship with the local community nurses who are always available for advice or visits to the home. A chiropodist, dentist and optician also visit the home as required. There are policies in place regarding the administration of medication. The staff who administer medication have all received training; one person has also been involved in training staff. The storage and recording of medication given was seen to be in order. Staff receive guidance regarding the way that care should be provided as part of their induction programme. Some staff have received training in working with people who have dementia. There are policies that also provide guidance. The staff who were on duty during the day were communicating effectively with service users and people were being treated in a respectful manner. People spoken with said that the staff treat them well. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14 and 15 Quality in this outcome area is good. People are usually provided with a lifestyle that satisfies their social, cultural and recreational interests and needs. Service users are supported to maintain contact with family and friends. People are encouraged to exercise some control over their lives. People are provided with a wholesome balanced diet in pleasing surroundings. EVIDENCE: The care plans that were seen included some comments regarding people’s previous interests. There is an activities room that is set up like a family kitchen with an outside area that is fenced off so that people do not wander out onto the path. Service users are provided with a programme of activities including the opportunity to go out in the minibus from time to time. There are dedicated members of staff who provide activities; on the day of the inspection there were no activities staff on duty and the activities room was not being used. Most people were in the communal areas, some were reading or watching television. Newspapers and magazines are available for people to order. People are encouraged to maintain contact with relatives and friends. Visitors are welcome before eight in the evening after which time they need to seek the permission of the manager to visit. The manager said that some people Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 12 have regular visits from family members and have occasional outings with them. The deputy manager said that relatives or solicitors manage service users’ financial affairs. People are encouraged to bring some personal possessions with them to the home. In some cases this makes the move away from their homes more manageable. People were free to use the communal areas of the home. Samples of menus were seen; these showed that people are provided with a balanced diet. Case records showed that people’s weight is monitored regularly. Special diets could be catered for. The chef had information about any allergies or food preferences. It was not clear that people are supported to understand the choice of food on the menu each day. There are large boards in the dining room where the daily menu can be written up. The mealtime was observed to be calm and staff were sensitive in helping people to eat their meal. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 13 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): 16 and 18 Quality in this outcome area is good. Service users and their relatives can be confident that their complaints or concerns will be listened to. Service users are protected from abuse. EVIDENCE: Sussex Health Care provides a complaints policy. The need to provide the policy in an appropriate format was discussed with the manager. People spoken with said they would tell a member of staff if they had a complaint. Two complaints had been documented and it was evident that both complaints had been investigated. There are policies and procedures regarding adult protection. Newly appointed staff are provided with information and guidance about what to do in the event of a concern that abuse may have occurred. Staff have all attended training on how to protect vulnerable adults. The Sussex Health Care policy regarding adult protection is in the process of being revised. The staff spoken with understood the need to immediately pass on any concerns that someone may be at risk. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 14 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): 19 and 26 Quality in this outcome area is adequate. Service users live in a home that is usually safe and well maintained. The home is usually clean and hygienic. EVIDENCE: There is a maintenance programme in place and some areas of the home have been redecorated and upgraded. The flooring in one of the lounges has been replaced. Not all the recommendations made by the fire officer in 2005 have yet been implemented. The grounds are well maintained. The laundry facilities are suitable for the needs of the people who live at Clemsfold House. The machines in both sluice rooms were out of order. The registered manager should ensure that there are measures in place to protect the health and welfare of service users. One of the cleaners was undertaking the NVQ award on the day of the inspection. It was not clear that there were risk assessments relating to the cleaning of communal areas while service users are using the room. The carpets in the communal areas were in need of Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 15 cleaning; the manager said that these issues would be addressed to ensure the protection of service users. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 16 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, 28, 29 and 30 Quality in this outcome area is good. Service users’ needs are met by the numbers and skill mix of staff. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: A sample of the staffing rotas was seen. The same numbers of care staff are employed each day. The two deputy managers were responsible for running the home in the absence of the manager. They explained that their shifts overlap to ensure that all the relevant information about service users and staff is communicated efficiently. There were no arrangements in place during the day for the work of the absent activities coordinators to be covered. There appeared to be sufficient numbers of staff on duty to meet the needs of service users. Sussex Health Care supports staff to register for the NVQ level two and three awards. There has been a good take up of this opportunity and currently ten staff have achieved the award. It was clear that staff are enthusiastic about this opportunity. Staff working at the head office of Sussex Health Care coordinate staff recruitment. The manager is involved in interviewing prospective staff to ensure that they would be suited to working with people who have dementia. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 17 The sample of staff records seen showed that all the necessary checks are carried out before new staff begin work to ensure that service users are protected. There is an induction and foundation programme so that staff are equipped with the skills that they need. An example of a recently completed induction programme showed that the member of staff had been given the support and advice she needed by her line manager. Sussex Health Care provides an ongoing training programme that includes sessions on working with people who have dementia. Staff spoken with said that they are encouraged to take up training opportunities. The manager said that all staff have recently had an appraisal to help identify their training needs. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35, 36 and 38 Quality in this outcome area is good. People live in a home that is run and managed by a person who is fit to be in charge. The home is run in the best interests of service users. Service users’ financial interests are safeguarded. Staff do not currently receive regular supervision to ensure that service users are fully protected. The health, safety and welfare of service users is not fully promoted and protected by the policies and practice in the home. EVIDENCE: Mrs Doreen Farrelly was registered by the Commission in June of this year. Mrs Farrelly has the knowledge and experience she needs to run the home. Sussex Health Care provides a quality assurance system whereby each month random samples of relatives are sent a questionnaire to complete if they wish to. The surveys are returned to senior managers who monitor and collate the Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 19 responses. The outcome of these surveys was not available and it was not clear how service users are included in the quality monitoring process. Relatives or solicitors manage the finances of all service users. Service users do not hold any money of their own. Staff said that any items that people need would be purchased by the home and invoices sent to those who manage their accounts. Staff at the head office of Sussex Health Care manage financial matters. There is a supervision policy however a system of formal supervision has not yet been fully implemented. The manager explained that senior staff who will be providing supervision are due to attend a course to provide them with the necessary skills. The staff spoken with said that the manager operates an open door policy and they feel well supported. There are policies in place regarding health and safety issues. The training records showed that staff have attended the mandatory training to ensure that they understand how to protect service users. There were individual risk assessments included in the sample of case records that were seen, however there were some areas where possible risks had not been identified and guidance provided to staff. The accident records were seen and it was clear that these are monitored in order to reduce individual risks where possible. The fire equipment was being serviced during the day. The requirements of the fire officer are in the process of being addressed. Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP36 Regulation Reg 18 Requirement The registered manager should ensure that all staff receive supervision as required. Timescale for action 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Worthing LO 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. Extracts may not be used or reproduced without the express permission of CSCI Clemsfold House DS0000014459.V310372.R01.S.doc Version 5.2 Page 23 - 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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