Inspection on 20/10/06 for Clere House

This inspection was carried out on 20th October 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 19/01/06

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 Maggie Prettyman Unannounced Inspection 20th October 2006 09:00 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.V317073.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. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clere House Address Pippin Close Ormesby St Margaret Great Yarmouth Norfolk NR29 3RW 01493 731291 01493 733180 clerehouse@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care 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) 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.V317073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 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.V317073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the home and current judgements for each outcome group. What the service does well: What has improved since the last inspection? A review and update of service user plans has been commenced. Medication training has recently been updated. More social activities are taking place and colourful information boards display past and future events. Some redecoration and re-carpeting has been undertaken. Extra care hours have been identified for critical times of service delivery. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 6 What they could do better: Some requirements and recommendations have been made at the end of this report. It should be noted that some of these are repeated from previous inspections. Requirements made are as follows; • • • • The update of care plans must be completed Redecoration of the home must be completed (Repeated) Adequate bathing facilities must be provided (Repeated) Agency staff vetting must be validated Recommendations made are as follows; • • • • • • • • • Service user guides should be available in all rooms Day care service users files should be reviewed if not done already Service user weights should be regularly recorded (Repeated) A file of compliments should be kept Adult protection training should be updated The appointed contractor should regularly check the call system Water temperature at point of supply should be checked and recorded Supervision should be given regularly (Repeated) Accidents and incidents should be audited for patterns and trends 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. The summary of this inspection report can be made available in other formats on request. Clere House DS0000035320.V317073.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 Clere House DS0000035320.V317073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. Prospective service users are given the information they need to make an informed choice about the home. Each service user has a written contract on file. Service user needs are appropriately assessed prior to admission. Short-term care service users have their needs assessed and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with service users and the duty manager confirmed that service users are given a service user guide prior to admission. These are not routinely placed in service users rooms. It is recommended that copies of the service user guide be placed in the rooms of long and short stay service users. Copies of contracts were seen in the service user files inspected. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 9 The service user group observed in the home reflected the registration of the home. One placement has not been successful this year, but this was due to factors beyond the control of the home. Day care and short stay service users are having short care plans devised for them. Work has begun which is hoped to be completed shortly. It is recommended that this work be completed. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. A plan of care is in place for all service users. Service users health care needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines. Service users are treated with respect and their dignity maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of service user files were inspected and found to be of a good standard, well organised and regularly reviewed. Some service user plans have yet to be updated. It is required that the remaining service user plans be updated to the same standard. Professional advice is taken for the prevention and treatment of pressure areas. A range of suitable equipment is available to support the health care needs of service users were seen. Medical services are accessed as needed. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 11 Some care staff are planned to attend MUST Nutrition Screening training. It is recommended that service user weights are consistently checked and recorded. A medication round was observed and seen to be conducted in an organised and professional manner. Records were checked and found to be in good order. Staff have recently received updated training in medication, and improvements have been made. All staff interaction with service users was seen to be kind, courteous and warm. Service users and their relatives interviewed report that staff are consistently supportive and professional. Mail was observed to be left unopened for individuals to open. A private telephone booth is available for service users to use. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Quality in this outcome area is good. Staff make great effort to provide a homely and stimulating environment. Links with the local community are maintained. Mealtimes are positive and social events. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was seen to be carefully and attractively decorated in anticipation of Halloween. Boards displaying past and future events were colourful, accessible and attractive. A recent African themed drum evening was a great success and enjoyed by those service users spoken to. Service users with particular leisure interests are encouraged to retain them. Family and friends were observed to visit freely during the inspection. A relative interviewed spoke highly of the home, its staff and services. A “Friends” group raises money for activities. Several community groups and local schools come regularly to the home. Recent improvements to the standard of meals provided have been made Food was observed to b e well presented and appealing. The kitchen staff were Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 13 found to be knowledgeable and committed to providing satisfying food. Kitchen areas inspected were clean and well organised, with foodstuffs appropriately stored. Of particular positive note is the home’s practice for care staff to sit and share meal times with service users, creating a friendly and sociable atmosphere. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service user complaints are listened to and acted upon. Service users are protected from abuse, but training in this area could be updated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints file was seen, with action taken in response to issues raised. The complaints procedure is displayed in the homes hallway. It is recommended that a compliments file be kept to record positive feedback about the home. Staff report that they have not recently had formal adult protection training. It is recommended that Adult protection training is made available to staff. Service users have lockable areas in their rooms to safely store personal items. Items of greater value are recorded and kept in the safe. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Quality in this outcome area is good. Service users live in a pleasant environment that is still in need of some redecoration. Service users have access to comfortable indoor and outdoor facilities. Bathing facilities are inadequate for the purpose of the home and its day care service users. Service users own rooms meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is accessible and suitable for its purpose. A tour of the premises demonstrated that maintenance is undertaken regularly. The home is still in need of redecoration. It is required that redecoration of the home Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 16 continues. The call system has not been recently serviced. It is required that the appointed contractor checks the call system. Communal areas both internally and externally were found to be pleasant and homely. The dining area has small tables, which were attractively laid. Furnishings are domestic and individual. Discussion of bathing facilities revealed that day care service users are also regularly using the very limited bathing facilities of the home. There is no doubt that this is an essential community service, but it serves to further highlight the need for the provider to provide more bathing facilities in the home. It is required that the provider makes further bathing facilities within the home. Service user individual rooms were seen to be attractively kept with many personal possessions on display. A tour of the premises demonstrated that the home is clean, pleasant and hygienic. Laundry facilities are quite cramped, but bed linens are washed by the laundry service and not in the home. An industrial washing machine is in place with suitable wash programmes. Some staff are booked to go on infection control training soon. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Sickness and vacancy levels are undermining planned staffing of the home. Service users are in safe hands at all times. The home must check the vetting of agency staff. Staff are trained to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently suffering staff shortages due to sickness and vacancies. Night staff vacancies are high. Agency staff have been used to meet this shortfall. Examination of the rota demonstrated that many shifts are being covered by staff working extra hours often at short notice. It is recommended that the provider appoint staff to temporary contracts to ease the problems faced by the team. Since the last inspection extra hours of cover have been added to the rota. Examination of staff training records demonstrated that a good percentage of staff are NVQ Qualified, and that this process is being continued. Examination of staff files demonstrated that staff are adequately checked before employment commences. Staff interviewed and observed on the day were found to be well trained and knowledgeable. Detailed training records for each member of staff were seen. Clere House DS0000035320.V317073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38 Quality in this outcome area is good. The home is run in the best interests of service users. Service users finances are protected. Staff supervision needs to be more regular. The health safety and welfare of service user and staff are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A quality assurance survey conducted in the last year has enabled the home to write a reflective annual service development plan. Residents have regular meetings, which are minuted, and action is taken to respond to requests and suggestions made. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 19 A selection of service users personal monies were inspected and found to be correct and properly recorded and audited. Inspection of staff files demonstrated that supervision is planned and does take place. However staff shortages mean that often supervision has to be postponed. It is recommended that staff receive regular supervision in line with the care standards. A tour of the building and examination of records demonstrated that the home is run with the safety and welfare of staff and service users in mind. Hazardous substances were safely stored. Evidence of servicing maintenance and repairs was seen. The home does not currently check water temperatures at point if supply. It is recommended that regular records of water temperature checks be held. The home does not currently audit accidents and incidents to identify patterns and trends so that areas and times of high risk may be identified. It is recommended that accidents and incidents be audited to identify preventable risks. Clere House DS0000035320.V317073.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 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 1 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 X 3 Clere House DS0000035320.V317073.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. 2. Standard OP19 OP21 Regulation 23.2 16.1 Requirement The registered person must ensure that the program of redecoration is completed. The registered person must ensure that the home has adequate bathing facilities. This requirement is repeated for the third time. The update of service user care plans commenced must be completed. Timescale for action 01/04/07 01/04/07 3 OP7 14 31/01/07 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. 2. Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that those residents, who visit the home for day care who have not had their care reviewed, are offered the opportunity to do so. It is recommended each resident be asked if they would be prepared to be weighed regularly to ensure up to date records are held in their plan of care. Repeated DS0000035320.V317073.R01.S.doc Version 5.2 Page 22 Clere House 3. OP36 4. 5. 6. 7. 8. 9. OP1 OP16 OP18 OP19 OP38 OP38 recommendation. 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. Repeated recommendation. The home should ensure that the service user guide is available to service users in their rooms. It is recommended that a record of compliments about the service are kept and audited. It is recommended that adult protection training be updated. It is recommended that the appointed contractor check the call system regularly. It is recommended that output water temperatures be regularly checked ad recorded. It is recommended that an audit of accidents and incidents be kept to identify any preventable patterns and trends. Clere House DS0000035320.V317073.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V317073.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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