CARE HOMES FOR OLDER PEOPLE
Clemsfold House Guildford Road Broadbridge Heath Horsham West Sussex RH12 3PW Lead Inspector
Mrs J Wright Unannounced Inspection 8th November 2005 10.30a 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.V259445.R01.S.doc Version 5.0 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.V259445.R01.S.doc Version 5.0 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 Mrs Linda Rose Mountford 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.V259445.R01.S.doc Version 5.0 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 accomodated. 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 accomodated. 7th June 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. The service is privately owned by Dr S Sachedina and Mr S Boghani. Mrs L Mountford is the registered manager. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. The first inspection, which was announced, was undertaken earlier in the year. At this inspection the Inspector looked at standards that were not looked at during the previous inspection, as well as any outstanding issues from the last report. The reader is advised to look at the reports of both inspections for a fuller picture of the home. The Manager was not available on the day of inspection, but the Assistant Manager, and the administrator very ably assisted the Inspector throughout the inspection. During this inspection the Inspector examined records of care being provided to residents; as well as records of any accidents, issues, concerns or complaints, to make sure that the residents at Clemsfold House were being taken care of. In addition the Inspector toured the building, inspecting all the rooms that the residents have access to, and shared a meal with the residents. The inspector met many residents, but due to their mental frailty, they were not all able to tell the Inspector what it was like living at Clemsfold House. They were, however, seen to be comfortable and well cared for, and appeared happy. A District Nurse spoken to on the day of inspection told the Inspector that she had no concerns at all about the care being provided by Clemsfold House, but suggested that staff training in the prevention of pressure sores would be of benefit to the home. At this inspection Clemsfold House was audited against the National Minimum Standards for Older Persons. The vast majority of the elements in each of the standards assessed were met, however requirements are made in this report for all staff members to receive the required fire training and supervision, and a recommendation is made that there be a photograph of all residents on file. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well:
All the residents, who the Inspector spoke to on the day of inspection, spoke very highly of the staff members, the food and their bedrooms. The building is maintained safely, although it was seen that parts of the home were in need of some redecoration. The vast majority of the records required by the Inspector on the day of inspection, were found to be in order. A “Clothes Party” was being held at the home on the day of inspection to enable those residents who are not able to access the shops, to choose any new clothes they may require. The Inspector was told that Clemsfold House does not use outside agency workers, thus ensuring that the residents always know their carers. During the course of the inspection each bedroom was visited and it was noted that many residents had brought personal possessions into the home, including pictures, photographs and numerous knick-knacks. The bedrooms were seen to have
Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 6 been recently vacuumed and dusted, and were free of clutter. Clemsfold House is located near a large pond, and the residents were clearly enjoying observing the numerous ducks and various wild birds, from the home’s windows. 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. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 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.V259445.R01.S.doc Version 5.0 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): 2 and 6 Each resident has a written contract/ statement of terms and conditions with the home. Clemsfold House does not offer intermediate care. EVIDENCE: The administrator assured the Inspector all residents, and their representatives receive a statement of the terms and conditions, which contain all the requirements of the National Minimum Standards. Copies of these are kept on file at Sussex Health Care’s headquarters. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 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): 11 Residents and their representatives are assured that at the time of their death, staff members will treat all residents and their family, with care, sensitivity and respect. EVIDENCE: The Inspector was informed that family or friends are offered a spare bedroom, if available, or a comfortable chair in the residents room, at the end of their life. From listening to the staff members, it would appear that staff treat residents who are dying, and their family and friends with respect, care and sensitivity. The Inspector was told that where deemed suitable, residents attend the funerals of fellow residents. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 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): 15 Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: On the day of inspection the Inspector shared a meal with the residents, which was clearly enjoyed by the residents. There is always a choice of food on offer at Clemsfold House. During the meal there was lively banter between staff members and residents, and the Inspector observed staff members assisting some residents, who were less able than others, in a sensitive and unassuming manner. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 11 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 Residents are protected from abuse. EVIDENCE: The current West Sussex Multi-Agency Policy and Procedure for protecting vulnerable adults from abuse was seen to be available in the home. The Inspector was assured that the home also have their own policies available to safeguard residents from abuse, plus the appropriate training for all staff members. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 12 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 Residents live in a well-maintained environment. EVIDENCE: At the previous inspection a requirement was made that all hot water outlets should be maintained at a safe level to ensure that people do not scald themselves. The person in charge assured the Inspector that this matter had been addressed, and water tested on the day of inspection was found to be a satisfactory temperature. On the day of inspection a door was wedged open, the staff member accompanying the Inspector was made aware of the safety implications surrounding this. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 13 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): 29 Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: From the records seen, it would appear that Clemsfold House operates a recruitment procedure, in which appropriate checks are made. Samples of staff records were examined. Those seen demonstrated that those procedures were followed in practice. All staff members are in receipt of a satisfactory Criminal Record Bureau check. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 14 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): 34, 35, 36, 37 and 38 Residents are safeguarded by the accounting and financial procedures of the home, their financial interests are safeguarded, staff are appropriately supervised, and residents’ rights and interests are safeguarded by the home’s record keeping and policies and procedures. EVIDENCE: The inspector saw that insurance cover is in place to meet the National Minimum Standards. There is a business and financial plan for the home, which would be made available upon request. Residents are encouraged to manage their own affairs with the help of relatives or advocates. Currently Clemsfold House does not offer formal bimonthly supervision to all care staff, and a requirement is made in this report for this matter to be addressed. The Assistant Manager assured the Inspector
Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 15 that regular, recorded supervision is to be introduced in line with the National Minimum Standards. Non-care staff and volunteers are also to be offered supervision. Clemsfold House had appropriate Health and Safety policies with systems available to support these. Risk assessments are completed for both the home and individual residents. Records of accidents, injuries and untoward incidents are recorded and reported appropriately. Training records indicated that staff had received induction training together with manual handling and infection control, however there was no evidence that all staff members had received the appropriate fire training, and a requirement is made in this report for this matter to be addressed. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 16 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 2 2 2 Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 17 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. 1 1 Standard OP36 OP38 Regulation 18 23 Requirement That all staff members receive supervision That all staff members receive the required fire training Timescale for action 31/12/05 30/11/05 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 OP37 Good Practice Recommendations That there be a photograph of all residents on file. Clemsfold House DS0000014459.V259445.R01.S.doc Version 5.0 Page 18 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
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