Inspection on 26/09/07 for Clevedon Court Residential Home

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Clevedon Court Residential Home 01/06/09

Clevedon Court Residential Home 24/09/08

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Clevedon Court Residential Home 1-3 Clevedon Road Weston Super Mare North Somerset BS23 1DA Lead Inspector Patricia Hellier Unannounced Inspection 26th September 2007 08:50 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 Clevedon Court Residential Home DS0000070055.V349267.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. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clevedon Court Residential Home Address 1-3 Clevedon Road Weston Super Mare North Somerset BS23 1DA 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) 01934 621981 01934 621981 ANJ & ASH Care Ltd Mrs Doreen Ann Harrop Care Home 22 Category(ies) of Learning disability (3), Old age, not falling registration, with number within any other category (22) of places Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) 2. Learning disability (Code LD) - maximum of 3 persons The maximum number of service users who can be accommodated is 22. New service Date of last inspection Brief Description of the Service: Clevedon Court provides personal care for up to 22 people elderly people. The home also cares for 3 elderly people with a learning disability. Clevedon Court is set just off the sea front, with level access to the town centre. All bedrooms have en-suite facilities, and two of the en-suites have bathing facilities. There are 21 bedrooms, one of which may be used as a double. At present, all are being used as singles. All bedrooms meet the new spatial standards and many exceed them. There is a passenger lift accessing both sides and both floors of the home, and a stair lift, which accesses three bedrooms on a mezzanine floor. The mezzanine level is also accessible via a ramp. The provider makes information available through a brochure and information pack. The information pack contains the Statement of Purpose and Service User guide and all relevant information about the home. The fees range between £356.37 and £400 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in September 2007. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 8.5 hours on two days. The Registered Manager, Mrs Doreen Harrop, was present for day one of the inspection. The Commission has received a complaint regarding poor practices and lack of staff at the home and these will looked into as part of the inspection process. The complaint was partially upheld. Evidence is contained in the relevant section of the report. Before the inspection the Annual Quality Assurance Assessment (AQAA) information about the home, requested by the Commission, was not returned. Surveys were sent to 15 relatives, 20 people who use the service, 3 GP’s and 3 Health Care Professionals. None of the surveys were returned. As this is a new service having recently been purchased by new owners it was only possible to review the registration report and any correspondence relating to this. The accumulated evidence for this report comes from the registration report and fieldwork that included the following: discussions with 8 residents, and 4 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “the staff come when I call”. What the service does well: The outcome for the residents is positive. For example 5 residents spoken with said, “the home is nice, the staff are kind and caring.” There is a good rapport between staff and residents. The staff work hard to ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. Residents feel that if they had something to complain about they would speak to a member of staff. One resident told of how he had complained and it had been dealt with quickly and to his satisfaction. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Clevedon Court Residential Home DS0000070055.V349267.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 Clevedon Court Residential Home DS0000070055.V349267.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Brochure and Service User Guide does not provide prospective residents with the required information to make an informed choice. The home’s assessment process is not always thorough to ensure that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: There is currently an outdated brochure available. On request a Statement of Purpose and Service User Guide is available. The Statement of Purpose is not comprehensive and does not clearly state the category of residents admitted to the home, or the arrangements for residents to attend religious services. Issues of equality and diversity are not mentioned. The complaints section does not include timescales and is inconsistent in its referral to the Commission for Social Care Inspection – at one point referring to it as Care Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 9 Standards. Other information regarding the admission precautions and the environment is clearly presented. process, fire Residents were not aware they had a contract of residency. Contracts with Social Services for residents funded by them were seen. These contracts did not state the room to be occupied. Residents funded by social services are not given a Terms and Conditions agreement. Also they are not given information regarding the weekly fees to be charged and how the amount is to be made up. This should be included for clarity for residents and their relatives and in line with the recommendations of the recent “Fair Price for Care report”. Privately funded residents do have a Contract including Terms and Conditions of residency but this does not include the room to be occupied. Three care records were inspected. There was no clear evidence of an assessment of needs being undertaken prior to admission to ensure that the home can meet the prospective residents needs. None of the care records inspected contained pre admission assessments, or assessments undertaken by Social Services. Thus the home was not able to demonstrate how it had assessed the needs of the residents to ensure that they would be able to meet them. The care records did show that needs had been assessed as part of the care planning process, however not all information requested as part of this assessment had been recorded. The assessment documentation was comprehensive and person centred with sections for recording physical health and well being, lifestyle choices and preferences and their current ability with daily tasks. Attention to detail when completing these would ensure clear information regarding care needs are identified to enable them to be met. A recently admitted resident when spoken with said, ‘I like it here, the staff are kind”. Care practices observed showed that staff had a good rapport with residents and sought to meet their needs. The staff are very welcoming and keen to ensure they provide a good standard of care. During the inspection it was evident that staff do not always have the skills and experience to meet the needs of the residents. Staff have not received training in managing people with learning difficulties or in the administration of insulin. Prospective residents and relatives are encouraged to visit the home to assess suitability. Clevedon Court Residential Home DS0000070055.V349267.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 7,8,9,10, Care plans do not always give clear, person centred information to enable staff to meet residents’ health and social care needs. The system in place for the management of medicines is poor and potentially puts residents’ at risk. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents. Three care records were inspected. The format of the records provides for clear and comprehensive information regarding the resident’s needs, and how best to assist the resident to met their needs, while promoting independence as able. Care plans are person centred and information recorded clearly reflects this approach. In two care plans information about allergies had not been recorded, while in another care plan past medical details, emergency contacts and hobbies and interests are not recorded. Care plan documentation lacked Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 11 attention to detail. Risk assessments had been completed but actions to minimise risk had not been stated. Staff interviewed had an understanding of the residents needs but not always the knowledge to meet these needs effectively. All staff observed have a caring approach and provide care as they see fit for the individual residents. In discussion with staff it was clear that they do not see the care plans as working documents to enable them to provide good person centred care. Care routines are conveyed by word of mouth. A handover book is used to convey daily information regarding changes to resident’s needs and care. This is not always written respectfully and does not provide for follow through of care needs identified. Information regarding care needs mentioned in the handover book are not translated to the care plans. Consistency of care to resolve problems is not evidenced. Care practices are affected by lack of information and inconsistency of care with residents needs not being met. In discussion with staff they had an awareness of the issues mentioned but were not always sure of the outcome. Two days after the inspection the provider outlined to the inspector the process she plans to implement to ensure clear communication of care needs and follow up to ensure good practice. None of the care plans showed resident or relative involvement. This practice needs to be implemented. Residents spoken with said, “the home is nice and the staff are good”. Care plans are reviewed on a monthly basis according to documentation, but no updates to care plans were noted. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with eight of the residents confirmed a satisfactory standard of personal care. Two residents said, “ it’s homely” another resident said, “people are very kind, we are well looked after”. Evidence was seen of regular visits by the chiropodist and optician and residents being taken to other appointments as needed. Residents’ comments supported this. Medication storage, receipt and disposal is poorly managed. It is not possible to obtain an audit trail of medication through the home. This potentially puts residents at risk, as there is scope for the mishandling of medicines. Staff were observed administering/ assisting with medicines for which they have not been trained. Staff must be trained by the District Nursing staff and deemed competent prior to the administration/ assistance with insulin and other medications requiring specialist techniques. Medication administration practices observed were satisfactory. Tablets are dispensed from a Nomad pack into a pot and given directly to the residents. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 12 The Medication Administration Record (MAR) sheets had some gaps. Hand transcriptions were seen on these sheets and were incomplete. In one instance there were no directions as to how the medication should be administered, another did not clearly state the dose of the medication. None of these hand transcriptions had been signed for accountability and protection purposes. There is no record of medicines returned to the pharmacy. A medicines fridge is available in the managers’ office but is not locked. The temperature is not monitored to ensure medicines are stored at the correct temperatures. The medication practices observed do not comply with the homes policy. The home has a medications policy that requires review to provide guidance on current good practice in a residential home setting. There specific policy for the administration of homely remedies with guidelines what preparations may be administered and within what timescales. should be developed in consultation with the local GP’s. clear is no as to This Residents who are self medicating had not signed a form to take responsibility for this. No evidence was available to show how the resident’s competency to self medicate was assessed, for their safety. The interactions of the care staff observed demonstrated respect for individuals and their right to privacy. Residents spoken to say, “the staff are very thoughtful and kind and treat you very well”. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home does not have an Equality and cultural and social needs and differences said, “We are all one happy family here”. cultural needs and differences in society needs for residents. Diversity policy that recognises the that are present in society. Staff Staff were aware of the social and and their role in facilitating these Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Social activities are limited, but routines are flexible. Residents’ right to choice and control over their lives is respected, and encouraged. Friendly staff always welcomes relatives and visitors EVIDENCE: Many residents commented on the atmosphere of the home. One person described it as nicely informal, and residents’ felt that their visitors are also helped to feel relaxed and at home. When asked about activities and their daily routine two residents said, “we just sit here and look out all day”. Another resident told the inspector “we have singing sometimes”. While the home is under new ownership the manager and staff remain the same, and residents do not feel there has been an impact on their lives from the change of ownership. The home does not have an activities plan as they feel the current resident group would not benefit from this. Staff spend time with residents on a 1:1 basis encouraging them with their hobbies and interests. Outings are arranged Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 14 for individual residents. An assessment of each resident’s activity ability is recorded in the care plan. During the inspection a number of residents were seen just sitting in their rooms or the lounge. No activities were observed being offered to residents, and staff did not seem able to sit and talk with them. One resident said “I make my own entertainment” and another said “we have singing sometimes”. No visitors or relatives were seen in the home during the course of the inspection. Thus it has not been possible to obtain feedback from relatives regarding the home. All residents said they were satisfied with the food. One resident questioned the nutritional value as supermarket “basics” foodstuffs are used. Fresh fruit and vegetables were used and available for residents. Menus showed a varied, balanced and nutritious diet. The meal on the day of inspection reflected this. Choice is not routinely offered but the cook says she is aware of residents’ preferences and choices. On the day of inspection an alternative was provided for residents who did not like the main meal offered. The dining room is homely and tables well presented. A number of staff have not received training in Food Hygiene and handling to ensure safe practice. A training session is planned in the next two months to ensure all staff have the knowledge and skills for the protection of residents. Not all foodstuffs stored in the fridge were properly labelled. There were no written records available to evidence good practice in the storing, cooking and handling of food. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 16,17,18 Residents are confident that they are listened to and their requests acted upon. Not all staff have a clear understanding about how to safeguard residents from abuse. EVIDENCE: The home has a complaints procedure that is displayed in the hall and is contained in the service user guide. It does not contain timescales to inform complainants when they can expect a response. Prior to the inspection the Commission had received an anonymous complaint regarding poor care practices and low staffing levels. The evidence from this inspection report partially upholds the complaint. Residents said that the manager and staff are very approachable and they would always raise any niggles with them. One resident who said they had done this, was very satisfied with the outcome. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, they do their best”. The manager says the home has received no complaints. There is no system arranged for the recording of complaints or niggles to show how residents views are listened to, or how they may have a say in the running of the home. Outcomes of issues Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 16 raised by residents are not recorded. The provider outlined to the inspector how she proposes to record all issues raised by residents and relatives and use them to inform the development of the home. All residents spoken with said they were “happy living at the home”; and that “staff are kind and caring”. The home does not have a copy of the North Somerset ‘No Secrets’ Guide. There is no procedure or policy available in the home for responding to allegations of abuse. The home does not have a Whistle blowing policy. In discussion with staff they felt that as a close-knit team there would not be a need for such a policy. Staff have a good understanding of what abuse is and the different forms it can take. They have not received any formal training regarding Safeguarding Adults and how to whistle blow should the need arise. Evidence of planned training for all staff in this area in the next 2 months was seen. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 19,20,21,22,23,24,25,26 Residents are provided with homely and comfortable surroundings. Health and safety issues are not well managed. Outdoor space is accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Infection control practices are not robust and provide potential for cross infection EVIDENCE: Many parts of the home are welcoming and comfortable with homely communal spaces. Residents’ rooms are personalised and comfortable. The lounge is furnished with a variety of suitable and comfortable chairs to suit residents’ needs. Some areas of the home are in need of redecoration. A maintenance and refurbishment plan was not available at the inspection. A Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 18 satisfactory business plan incorporating these issues was seen for the registration of the new owners three months ago. Outdoor space is accessible and an adequate sitting area is provided for residents’ enjoyment. Residents’ rooms are personalised and comfortable. All rooms are provided with ensuite facilities. The décor, fixtures and fittings are in satisfactory order. Areas of the home need redecoration and the provider said she was aware of this. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility, and aid independence within the home. There is also a stair lift to the mezzanine floor and ramp access from the first floor. The home has sufficient bathroom facilities with aids for the benefit of residents. Equipment was clean and well maintained. A number of fire doors are not self-closing and do not fit flush to the doorframe to provide the necessary seal for the safety of residents. (further comment about this is made in the management section of the report). Although hot water outlets to baths are thermostatically controlled there was no thermometer for checking the temperature of bath water to prevent potential scalding. The home was and free from offensive odours throughout. Hand washing facilities in communal areas although available were not satisfactory, with bars of soap and linen towels that are key ways of spreading infection. The laundry facilities were well organised. The flooring is broken in some areas and potentially provides a breeding ground for infection. The management of soiled linen does not provide the necessary safeguards for the protection of residents. Although there is a sink in the laundry there were no hand washing facilities available and staff describe how they walk through the kitchen area to the staff room toilet for hand washing. The home’s infection control policy is out of date and should be reviewed to provide best practice guidance for staff and the protection of residents. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are poor and do not provide the necessary safeguards to protect residents. Staff has not received the necessary training to ensure they are competent to do their job. EVIDENCE: The staffing rotas were not available for inspection to ascertain satisfactory staffing levels throughout the day. Staffing rotas were supplied following the inspection. Staffing levels on the day of inspection were satisfactory with three care staff supported by two cleaners and a cook. The manager was present in a supernumerary capacity. Staffing levels in the afternoons and evening are variable but usually consist of 2 carers. Staffing levels should be kept under review to ensure residents needs can be met and activities provided. Both staff and residents spoken with felt that there is sufficient staff to meet residents needs throughout the day. At night there are two waking staff. The manager should keep the staffing levels under review against the changing needs of the residents. The home has a Key Worker system in place for all residents. Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 20 “how nice the staff are”, and two people gave examples of particular instances of kindness. Staff interviewed said, “the home is a happy place to work, we are like one big family”. Recruitment practices for the new staff employed are poor. Application forms were incomplete and had not been dated or signed. There was no conviction declaration or information of medical details included in the application form. Nowhere in the recruitment file was there a start date. The deputy manager worked out the suspected start dates from timesheets. Three records inspected did not have Criminal Record Bureau checks prior to their commencement of employment at the home. One record did not have a POVA first completed before commencement of employment. Written references were not dated or signed and did not state the name of the person they were referring to Following the inspection the provider has submitted new documentation for the recruitment of staff which, if accurately completed, looks as though it will provide the necessary safeguards for the protection of residents. All three files did not contain evidence of qualifications obtained. None of the records inspected had evidence of induction or mandatory training, and no supervision records were available. One relatively new member induction, which covered recommended that staff programme to ensure they needs. of staff told the inspector that she had received an Fire and Health and Safety issues. It is undertake the Common Induction Standards have the skills and knowledge to meet residents’ The home currently has 40 of staff with an NVQ qualification. At present no further staff are undertaking the qualification. Training in the last year has been limited. Staff have not received annual mandatory training in Fire procedures, Manual Handling or Safeguarding Adults. There are no records of specialist training received in the last year. Staff interviewed said they had not received training in the administration of medicines and Food Handling and Hygiene since their employment at the home more that a year ago. Staff said they had not received training in specialist areas to meet resident needs. Training must be provided to ensure a competent staff team to meet residents’ needs. Evidence was seen of planned training to provide staff with mandatory training updates in the next 2 months. Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 31,32,33,35,36,37,38 The manager provides leadership and guidance to staff in the provision of care. The underpinning management structures of the home are lacking in some areas to ensure the smooth running and safety of the home. Quality assurance processes in the home are not formal demonstrating that the home consults with residents, families and visiting professionals. Residents’ views are sought and acted on, but a formalised system is not in place. The management of resident’s monies are handled safely by the home Health and safety issues are not regularly monitored in the home and a safe environment not always maintained. EVIDENCE: Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 22 The manager is well qualified and has a number of years experience in this area, and is supported by a deputy manager. She gives leadership, guidance and direction to staff but the information is not always up to date, to ensure that staff are knowledgeable and competent to meet residents’ needs. Attention to detail in communication is not evidenced and this affects care practices. Entries in the Handover book show lack of continuity and attention to residents needs. Residents feel she is approachable, available and seeks to ensure all their needs are met. One resident said she ‘can’t do enough’, ‘she is always helping”. Staff interviewed stated that they felt supported by an approachable manager. Staff said that they are a close-knit team and work closely with the manager. Policies and practice guidance are provided in the home. They are not signed and are not tailored to the homes setting, as they have been taken from the registered nursing homes association with no alterations. It is recommended that all polices are reviewed, signed and dated to ensure best practice policy and guidance is provided. The home does not have a formal quality assurance system. As this is a new service the provider told the inspector that she was planning to implement a robust system to demonstrate how residents and relatives views are listened to and used in the management of the home. Residents’ pocket monies held by the home were inspected. Two of the three records inspected did not tally. Clear records and receipts were present. All entries are supported by one signature for any transactions. It is recommended that two signatures support entries to ensure the safeguarding of all concerned. The manager said supervision for staff is provided through observation and joint working. Records inspected showed no supervision had been undertaken in the last three months, since the home has been under new ownership. Staff interviewed said they had not received supervision for six to nine months or more. Supervision of staff is required to ensure that staff have the skills and knowledge to meet the resident in a competent and safe manner and in accordance with the aims and objectives of the home. Supervision records need to show that supervision is provided at least six times a year and includes discussion regarding care practices and training needs. The home records and stored securely and used in accordance with the Data protection Act 1998. A number of records e.g. the care plans, staff files are not accurately maintained and up to date and this affects the effective and efficient running of the business. Clear, accurate and up to date records should be maintained for efficient running of the home and the benefit of Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 23 residents. A clear management structure needs to be put in place to ensure the smooth running of the home when the manager is not present. During the inspection post from 4 weeks ago was found unopened on the managers desk. The provider discussed with the manager at inspection the development of a new management system to ensure clear lines of accountability and the smooth running of the home at all times. Records were not available to show if regular safety and fire checks are carried out. Certificates of safety checks, servicing of equipment and other required safety inspections were seen. Some of the certificates were out of date. There are a number of issues relating to the fire safety in the home with at least four bedrooms and the door at the top of the stairs being ill-fitting fire doors, and lack of fire training for staff. A number of fire doors throughout the home were wedged open. There was no evidence a fire risk assessment has been undertaken. Staff spoken to confirmed that they had not received regular fire instruction or drills in the last year. The manager and provider stated they are aware of the issues regarding the fire doors and are in the process of obtaining quotes for work needed. The provider is aware of the need for a fire risk assessment opt be undertaken. . Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 24 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 1 2 1 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 1 2 3 3 3 3 3 3 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 1 2 1 Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 25 NO 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 OP1 Regulation 4.1 Requirement The Statement of Purpose shall contain all the elements listed in Schedule 1. An assessment of needs must be made prior to admission of a prospective resident to the home to demonstrate the home can meet the needs. Care Plans must be prepared in consultation with the resident to show how the health and welfare needs are to be met. Timescale for action 31/10/07 2 OP3 14.1 31/10/07 3 OP7 15 31/10/07 4 OP7 15 Care plans must be updated with 31/10/07 changes to health and personal care needs, and used to ensure a consistency of care is provided for the benefit of the residents. The system for administration 31/10/07 and storage of medicines to be changed to provide safe practice. To provide a policy for the handling of abuse in line with the Local ‘No Secrets’ guidance. To provide staff training in DS0000070055.V349267.R01.S.doc 5 OP9 13.2 6 OP18 13.6 21/11/07 Clevedon Court Residential Home Version 5.2 Page 26 7 OP26 16.2 (j) safeguarding adults. The registered person must ensure that there are adequate hand washing facilities for maintaining good infection control practices within the home. All required information and checks must be undertaken prior to a person commencing employment at the home Staff must be provided with the appropriate training for the work they are to perform. The registered person must ensure that persons working in the home are appropriately supervised. The registered person must make suitable arrangements for containing fires and ensuring that persons working at the home have suitable training in fire prevention. 31/10/07 8 OP29 19.1 Schedule 2 18.1 (c) 31/10/07 9 OP30 30/11/07 10 OP36 18.2 31/10/07 11 OP38 23.4 31/10/07 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 Refer to Standard OP2 Good Practice Recommendations To amend the Terms and Conditions of residency document to show the way in which the fees are made up and who is contributing what amount. To state the room to be occupied. The registered person to ensure that staff have the skills and abilities to meet residents needs. 2 OP4 Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 27 3 4 5 6 7 8 9 10 OP7 OP12 OP15 OP16 OP19 OP27 OP31 OP35 Ensure attention to detail in recording information in care plans. To ensure that residents are offered activities regularly and this can be evidenced. To ensure that clear written records of the management of food are maintained for the safety of residents. To include timescales in the complaint procedure To ensure the refurbishment of identified areas of the home for the benefit of residents. To keep the staffing levels under review to ensure sufficient numbers to meet residents needs. The development of a robust management system to ensure the home meets its stated purpose for the benefit of residents. The development of a robust system of managing finances to ensure the protection of residents’ monies. The use of two signatories when handling resident’s monies. To ensure attention to detail in all record keeping for the provision of clear and full information, to residents, relatives and staff. 11 OP37 Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Clevedon Court Residential Home DS0000070055.V349267.R01.S.doc Version 5.2 Page 29 - 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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