Inspection on 19/01/06 for Clere House

This inspection was carried out on 19th January 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

Clere House 24/02/09

Clere House 20/10/06

Clere House 30/08/05

Clere House 01/03/05

Clere House 09/09/04

Clere House 02/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Clere House Pippin Close Ormesby St Margaret Great Yarmouth Norfolk NR29 3RW Lead Inspector Linda Wells Unannounced Inspection 19th January 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clere House Address Pippin Close Ormesby St Margaret Great Yarmouth Norfolk NR29 3RW 01493 731291 01493 733180 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) Norfolk County Council-Community Care Mrs Carole Patricia Nisbett Care Home 22 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (20) of places Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Clere House is a single storey, residential care home providing care and accommodation to up to 22 older people and is owned and run by Norfolk County Council. All bedrooms are single rooms and contain a washbasin and there is communal use of an adapted, walk-in shower room, a bathroom, eight toilets, two lounges, a large lounge area that is divided into two areas and a dining room. There is a small, well-kept garden with seating in a patio area to the front and the rear of the property and roadside parking. The home is situated in a residential area, within the rural village of Ormesby-St-Margaret. Local amenities include shops, a medical centre, post office and pubs. There is a bus service to both Great Yarmouth and Norwich. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken on the 19th January 2006 over four hours and was carried out as part of a routine inspection plan. On the day of inspection nineteen residents were living at the home, one resident was staying for respite care and an additional two people were visiting the home for day care. Residents were seen to be having a meal, sitting in the lounges or their bedroom listening to the radio, reading or watching television. The inspection took the form of a tour of the premises, individual discussion with eight residents, three staff members, a temporary care co-ordinator and the manager, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The requirements and recommendations from the last inspection have mostly been complied with but there is still more to do to completely ensure that residents are protected fully, consulted and the environment well maintained in all areas. The following two requirements and four recommendations were made to further improve the experience of living and working at the home for residents and staff. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 6 • • • • • • An additional bathroom must be provided to ensure adequate bathing facilities in the home. (Repeated requirement) The home must produce and commence a program of redecoration giving priority to those areas where walls are cracked and chipped. (Repeated requirement) It is recommended that a copy of the results and action plan produced from the quality assurance audit carried out in the home be sent to CSCI to demonstrate the level of satisfaction on the standard of services provided and planned improvements. It is recommended that those staff who have not received regular supervision do so to ensure the needs of residents are known, review work practise and plan training. It is recommended that those residents, who visit the home for day care, be offered the opportunity to take part in a review of the service they receive to ensure their needs are met. It is recommended each resident be weighed regularly, if they wish, to ensure up to date records are held in their plan of care. 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. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The admission procedure and written information available is good and fully enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live, stay or visit there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The manager said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. She said residents, their family or friends sometimes visited the home, that she or one of the care co-ordinators often visited residents in their own home and that residents were admitted on a one-month trial basis. One resident spoken to who had lived at the home for three months said that she had visited the home prior to admission, had received information about the home and that staff had made her feel welcome and assisted her to settle in. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11 The health, social and personal care needs of residents were met, they were well cared for but some records were not up to date. EVIDENCE: Residents said they were well looked after and four individual plans of care were examined and found to contain relevant health, social and personal care information, photograph, data protection agreement, care needs, weight records, reviews, daily records, risk assessments, choices, past history, list of falls, visiting professionals, and the signature of the resident. However, weight records were not in place or up to date for all residents and not all of those residents who visited the home for day care had taken part in a review of the service they receive. Two recommendations were made that up to date weight records be held for those residents who agree to being weighed,to aid in the monitoring of their health and that reviews be carried out with each resident to ensure their needs are met. Medication policies and procedures were seen, a member of staff was observed safely administering medication and the records held demonstrated that medication was administered, recorded and stored correctly. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 10 Residents spoken to said that staff treated them with respect and that their privacy was upheld. The records held on the arrangements at death for residents demonstrated that they had been consulted and their wishes were known. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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, 14, 15 There are social and creative activities and a choice of meals that provide some interest and reflect the preferences of the residents. EVIDENCE: Residents said that they took part in some activities and records were seen to demonstrate that regular activities were provided such as musical entertainment once a month, local groups visiting the home on special occasions, outings and bingo. The manager said the daily activities were regularly reviewed with residents at the residents meetings and that it was often hard to motivate residents to do more than watch the television. She said that a retired member of staff visited the home weekly to organise games, do a quiz or nail care. Staff spoken to said that they very rarely had the time to sit and talk to residents or organise an activity due to the workload and the high dependency care needs of the more frail residents. The staff gave examples of how they work with residents to support them in their daily lives and in maintaining friendships and relationships by encouraging each resident to be independent and to make choices whilst ensuring that the rights of each resident were promoted and protected. Residents all said that they enjoyed most of the meals and two spoken to said that their special dietary needs were catered for. Observation of the main Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 12 meal, menus and records revealed that they were balanced, wholesome and varied and that records were kept of any alternatives provided to aid in the monitoring of the nutritional health of each resident. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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, 17, 18 The home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: Two complaints had been received by the home and records demonstrated that the complaints were investigated and the appropriate action taken. The residents spoken to all agreed that if they had reason to complain they would speak to staff or the manager and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. The legal rights of residents are protected and records demonstrated that some residents have advocates and are encouraged to take part in the local and national elections by voting. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and records showed that staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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, 20, 21, 25, 26, The standard of the environment within this home is mainly satisfactory but does not fully provide residents with an attractive, safe and homely place to live. EVIDENCE: A tour of the building revealed that residents live in a home that is comfortable and decorated and furnished to a reasonable standard in most areas but is in need of redecoration in some areas where walls are cracked, chipped and the decoration worn and/or tired looking. A requirement was repeated that the home be redecorated and the manager said that arrangements were in the process of being made for the work to be completed. The home had recently had one bathroom refurbished and adapted into a walk-in shower with tracking hoist and whilst it meets the preferences and specialist needs of some residents and makes life easier for the hairdresser it has resulted in the home having the use of only one bath. The Homecare service use the bath facility three days a week to bath those residents visiting the home for day care. Staff spoken to said that residents mainly preferred to Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 15 have a bath and that problems have arisen where residents have not been able to have a bath when they wish. A requirement has been repeated that an additional bathroom must be provided to ensure adequate bathing facilities in the home. Residents said that they benefited from a home that was comfortable, clean and tidy and this was found during the tour of the building. Residents were seen to have personalised their bedrooms and each wing of the home had adequate equipment and toilets that were adapted to suit the needs of the residents. Infection control measures were seen to be in place and the laundry room contained a service washing machine and tumble dryer. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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, 30 The needs of residents are met, staff members are competent and the procedure for the recruitment and training of staff provides safeguards to offer protection for the people living at and visiting the home. EVIDENCE: Residents said that they were well cared for and the staff spoken to said that staffing levels had been slightly increased and that there were enough staff on duty to meet the needs of residents if all posts were covered in times of sickness and annual leave and staffing levels were increased when the dependency of residents and day care visitors increased. The manager said that she had just been given permission to increase staffing levels in line with the increased dependencies of residents but the home was experiencing high levels of sickness of care co-ordinator staff, that senior care staff had been used to cover their posts and that every effort was made to fully cover shifts. When the staffing levels have been increased and are in post standard 27 will be met. The staff members spoken to said that they were supported by the senior care staff and the manager, handover and staff meetings and demonstrated that they were aware of their role and responsibilities. Records showed that residents were protected by the staff recruitment checks that had been carried out. CRB checks, references, personal details, proof of identity and a photograph of each staff member were seen to be held in the file of each staff member. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 17 Records demonstrated that staff members had a mix of experience and skills and the manager said that seven staff had completed NVQ2 and three were in the process of completing and one had completed NVQ3 and one was undertaking. Certificates showed that an induction, foundation and updated training programs were undertaken by all staff to enable them to gain the knowledge necessary for the range of needs of residents living at the home. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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, 34, 36, 38 The manager is supported by the senior staff in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care. EVIDENCE: The manager has been in post for five years, has twenty-two years experience of working in the care setting and has completed the NVQ4 Registered Managers award. She said that her management hours had just been increased to full time and that once she had recruited a care co-ordinator to replace her she would be able to relinquish her care co-ordinator hours and work full time. Residents and staff said that the home was well run and records demonstrated that residents are protected by the management and administration procedures carried out in the home. Policies and procedures have been produced and were seen on all aspects of the home and service provided. The Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 19 records held were found to promote and protect the rights and best interests of each service user. Staff said that they worked as a team and records demonstrated that not all staff had received regular supervision and in two instances not for over nine months. A recommendation was made that all staff receive supervision at least six times a year to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs are identified, clarified and reviewed. A Quality Assurance system is in place that takes into account the views of everyone living, visiting and working in the home however, a recommendation was made that a copy of the results and action plan produced from the quality assurance audit carried out in the home be sent to CSCI to demonstrate the level of satisfaction on the standard of services provided and planned improvements. The manager successfully monitored identified financial budgets for the home and there was no reason to doubt that the financial security of Norfolk County Council was not sound. The servicing and testing of all equipment had been carried out and relevant and timely certificates were held to ensure that the health and safety of residents is protected. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 X X X 3 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 X 2 X 3 Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 21 YES 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 OP19 Regulation 23.2 Requirement The registered person must ensure that a program of redecoration is provided and commenced. (Previous timescale of 31st December 2005 has not been met) The registered person must ensure that the home has adequate bathing facilities. (Previous timescale of 31st December 2005 has not been met) Timescale for action 01/08/06 2. OP21 16.1 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that those residents, who visit the home for day care, be offered the opportunity to take part in a review of the service they receive to ensure their needs are met. It is recommended each resident be asked if they would be prepared to be weighed regularly to ensure up to date DS0000035320.V276114.R01.S.doc Version 5.1 Page 22 2. OP8 Clere House 3. OP33 4. OP36 records are held in their plan of care. It is recommended that a copy of the results and action plan produced from the quality assurance audit carried out in the home be sent to CSCI to demonstrate the level of satisfaction on the standard of services provided and planned improvements. It is recommended that those staff who have not received regular supervision do so to ensure the needs of residents are known, review work practise and plan training. Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Clere House DS0000035320.V276114.R01.S.doc Version 5.1 Page 24 - 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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