Inspection on 07/06/05 for Clemsfold House

This inspection was carried out on 7th 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

Clemsfold House 24/11/09

Clemsfold House 29/09/09

Clemsfold House 22/06/09

Clemsfold House 01/11/07

Clemsfold House 31/08/06

Clemsfold House 08/11/05

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 Annette Turner Announced 07 June 2005 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. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clemsfold House Address Guildford Road, Broadbridge Heath, Horsham, West Sussex, RH12 3PW 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) 01403 790312 Dr Shafik Hussein Sachdenia and Mr Shiraz Boghanie Mrs Linda Mountford CRH - Care Home 48 Category(ies) of DE(E) Dementia over 65 - 48 registration, with number MD(E) Mental Disorder over 65 - 48 of places DE Dementia 40 years to 65 years - 8 Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Forty eight (48) persons in the category Dementia elderly (DE)(E). Forty eight (48) service users in total may be accommodated. To include up to eight (8) persons in 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. Date of last inspection 05 October 2004 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. The service is privately owned by Dr S Sachedina and Mr S Boghani. Mrs L Mountford is the registered manager. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place during a morning and afternoon of Tuesday 7th June. During the inspection a tour of the building took place. There were forty people accommodated. Time was spent talking with service users, a visiting relative and a member of staff in the activities room. Six other service users were spoken with during the day and eight staff as well as the registered manager. The inspector examined records about the services provided at Clemsfold House. Records of accidents, complaints and health and safety were also seen to make sure that people staying at Clemsfold House are well cared for. Eighteen relatives, a GP and a chiropodist returned comment cards to the Commission and all but one indicated that they are satisfied with the care provided. Care staff supported all the service users to complete comment cards and the majority were positive about the care that staff provide. What the service does well: What has improved since the last inspection? Care plans that are written from the service user’s point of view are beginning to be introduced. A safety gate has been fitted to a short flight of steps in the reception area to prevent the risk of people falling. Safety glass has been fitted in some windows where a risk of harm to service users had been identified. An additional member of care staff is employed in the evenings to make sure people have the support that they need. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4and 5 Before moving to Clemsfold House people are given sufficient information about the services the home provides in order for them to make a choice about moving there. The manager carries out a comprehensive pre-assessment to make sure that people know that their needs can be met. There are opportunities to visit Clemsfold House before a final decision about moving is made. EVIDENCE: People are provided with the information that they need about the services provided at Clemsfold House in the Statement of Purpose and Service User Guide. There were comprehensive pre-assessment forms on the case records that were seen. The registered manager confirmed that she visits people at home or in hospital to go through the assessment to make sure that their needs can be met. The manager also said that people are invited to spend the day at Clemsfold House and to stay for lunch before they make a decision to move there. The relative spoken with said that she was given the information that she needed before her mother moved in. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 The care plans provide information to staff about the care that people need and the way that care should be provided. It was clear from comments made and the records that were seen that service users receive the personal and healthcare that they need. EVIDENCE: The inspector read a sample of care plans. A new person-centred system of recording care plans is being introduced. This will provide a way for service users to be the focus of the care planning process. The documents currently being used were discussed with the manager as they refer to ‘nursing interventions’ rather than health and social care needs. It was clear that care plans are reviewed regularly. Several people had indicated that they do not always feel fully informed about changes in care for their relative. This was discussed with the manager who said that relatives are invited to reviews by key working staff following discussion with the service user. People spoken with said they receive the healthcare that they need. A GP visits the home every week and is available for advice and support. The personal and healthcare needs of service users were noted in their care plans. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 A variety of social activities are available to satisfy the social needs of service users. People can take part in group or individual activities with staff support. The weekly outings provide a recreational interest for people. Service users are encouraged to maintain contact with their friends and families. Visitors are encouraged and made to feel welcomed at Clemsfold House. Service users are provided with a varied and nutritious diet of home cooked food. EVIDENCE: There is a comfortable activities room that has been furnished to resemble a domestic kitchen with all the utensils necessary for cooking and a variety of other activities. There are part time activities staff who work separately from the care team. Service users, visitors and staff were taking part in a variety of activities in a relaxed atmosphere. It was clear that people are supported to maintain their independence skills and people said that they enjoy cooking activities. There is an enclosed garden area with covered shelter in hot weather so that people can spend time in the fresh air. Outings are available once a twice a week for some service users however the time is limited to two hours because the minibus is needed elsewhere. This leaves little time to visit places of interest further afield or to have a snack while out. Comments from relatives and service users indicated that visitors are encouraged to spend time with their family member. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 11 The lunch was being prepared and the kitchen records were seen. The food looked healthy and appetising. The menu is varied with an emphasis on providing fresh food. There are choices available and special diets are catered for. The meal-time was relaxed and people were supported to enjoy their food at their own speed. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 standard(s) 16, 17 and 18 Complaints are recorded and investigated appropriately. People said that they feel staff listen to them. People’s right to vote is protected and everyone is on the electoral register. The adult protection policies and staff training ensure that service users are protected from abuse. EVIDENCE: There is a complaints policy that is available on the notice boards. There is a complaints book next to the visitor’s book in the reception area. Service users said that they know who to talk to if they have any concerns and all but one indicated that they feel safe at Clemsfold House. The complaints that were recorded had been investigated and responded to. One complaint had been made directly to the Commission. The staff spoken with were aware of the adult protection policy and knew what to do in the event of a suspicion that abuse may have occurred. They said that they had received training about adult abuse. The manager said that several people had been supported to cast a postal vote at the recent elections. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users are provided with a homely and safe environment. When areas of risk are identified action is taken to ensure that people are safe. The requirements made by the fire officer are being implemented. The bedrooms are comfortable and meet the needs of service users. The home was clean and comfortable. All hot water outlets should be maintained at a safe level to ensure that people do not scald themselves. EVIDENCE: People spoken with said that they like their rooms and have everything that they need. There is an ongoing programme of refurbishment. A vacant room was being decorated prior to someone moving in. The fire officer had recently carried out an inspection of the premises. He has made a number of requirements that are being addressed. Service users are provided with the equipment they need. The manager reported a good relationship with the local healthcare staff to ensure that people have pressure relief equipment if they need it. There are sufficient toilets, shower and bathing facilities. There are several communal areas so that people can choose where they like to spend Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 14 their time. Most people were making use of the communal areas at the time of the inspection. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 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 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 and 30 Staff are provided with a comprehensive induction and training programme to ensure that they understand how to meet the needs of service users. There are sufficient numbers of staff on the duty rota. Staff said that they work well as a team and are well supported in their work. EVIDENCE: The staff spoken with said that they had been given a good induction and that they are encouraged to take part in training that will help them understand the needs of service users. Most staff had undertaken courses for working with people who have dementia or memory loss. The staff spoken with said that they feel very supported in their work and that they work well as a staff team. The duty rota showed that there are eight or nine care staff on duty in the morning, six in the evening and three waking night staff. There has been an additional member of staff on duty in the evening recently. The staff spoken with said that they feel they have time to carry out their duties and to spend time with individual service users. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 16 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, 37, and 38 The home is well run with clear leadership and lines of accountability. The quality assurance systems work well to monitor and improve the experience of service users. The health and safety of service users is assessed and protected in most areas of the home. Hot water temperatures should be maintained at safe levels to prevent scalding. EVIDENCE: The registered manager is experienced and qualified to run a care home. Staff said that they feel well supported and able to discuss any issues or concerns at staff meetings. They said that the manager has an open door policy and is available to them for support and advice. Sussex Health Care has a quality monitoring system and sends out questionnaires randomly to service users, relatives and staff. There was a positive response to the comment cards sent out by the Commission. Internal systems and Regulation 26 reports ensure that the quality of care for service users is kept under review. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 17 The records that were seen showed that the rights and best interests of people staying at Clemsfold are safeguarded. The health and safety risk assessments and monitoring systems are up to date. The fire officer has recently carried out an inspection. Records showed that hot water temperatures in a number of hand basins were higher than the recommended levels to ensure the safety of service users. Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 18 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 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 3 3 x x x 3 2 Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 19 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 38 Regulation Reg 13 Requirement The health and safety of service users needs to be protected by ensuring that temperstures of water from hot water outlets is maintained at safe levels. Timescale for action 31/07/05 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 Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI Clemsfold House H60-H11 S14459 Clemsfold House V222431 070605 Stage 4.doc Version 1.30 Page 21 - 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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