Inspection on 14/04/05 for Clore Manor

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clore Manor 04/06/07

Clore Manor 24/07/06

Clore Manor 24/01/06

Clore Manor 12/10/04

Clore Manor 18/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE CLORE MANOR 160-162 Great North Way Hendon London NW4 1EH Lead Inspector David Hastings Unannounced 14 April 2005 at 09.30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. CLORE MANOR Version 1.10 Page 3 SERVICE INFORMATION Name of service Clore Manor Address 160-162 Great North Way, Hendon, London NW4 1EH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8203 1511 020 8202 6426 Simon Morris for Jewish Care Mr Chrysogonus Diala PC Care Home only 72 Category(ies) of DE(E) Dementia over 65 registration, with number OP Old Age of places CLORE MANOR Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 12th October 2004 Brief Description of the Service: Clore Manor is registered to provide care for seventy-two elderly people some of whom have problems associated with dementia. The home is operated by Jewish Care and therefore observes a lifestyle promoting Jewish beliefs and culture. The home is located off the busy Great North Way in Hendon, on the edge of a residential area. It is a short drive to local shops and businesses and Brent Cross shopping centre. The stated purpose of care practice is to provide a homely, relaxed and safe environment for the residents, with an emphasis on individual differences. The aim is to treat residents with dignity and respect, where they can live as individuals leading as full and active lives as their physical and emotional condition will allow. The main building is on three floors. The two extensions that have been added over the years are on two levels at each end of the original building. The home has been effectively divided into three units. One of these, accommodating fourteen service users is designated as a dementia care unit. All service users bedrooms have en suite facilities, with a toilet and bath or shower. Each of the three units has communal sitting and dining space. There is a lift to assist people with mobility problems to gain access to the upper floors. CLORE MANOR Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 14th April 2005 and lasted for five hours. Seven staff and twelve residents were spoken to. A partial tour of the premises took place and care records were inspected. The inspector was assisted throughout the inspection by the manager and deputy manager. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. CLORE MANOR Version 1.10 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection CLORE MANOR Version 1.10 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 4 The home provides good information to prospective service users so that they can make an informed choice about where to live. Staff at the home have an excellent understanding of the needs of people living there and how these needs are to be met. EVIDENCE: The service user guide has been updated to include the statement of purpose, a colour brochure, and thus details of the relevant qualifications and experience of the registered provider, manager and staff. It also includes details of how to access the latest inspection report, and service users views of the home. A copy of this guide had been given to all service users in the home, and the manager advised that copies are also sent to prospective service users on enquiry to the home. On the day of the inspection the inspector saw copies of the service user guide in a number of rooms. The inspector spoke to a number of service users who confirmed that the staff at the home were able to meet their needs. One service user said that staff at the home “really try to meet my wishes”. Staff interviewed had an excellent understanding of individual service users’ needs and how these needs were to be met. CLORE MANOR Version 1.10 Page 8 CLORE MANOR Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Staff at the home are aware of and are able to meet the health, personal and social care needs of service users. There is good access to health care professionals. Staff respect service users’ rights and privacy. Better systems will need to be implemented with regard to the administration of medication in the annex unit, as at present this is not been carried out to an acceptable standard. EVIDENCE: Five service user plans were examined. A requirement was issued at the last inspection that these plans contain more detailed information so that staff are aware of all the needs of service users. Plans have improved since the last inspection however the organisation is currently implementing a new system of care plans, which should provide a clearer approach for staff. These plans will be examined at the next inspection. CLORE MANOR Version 1.10 Page 10 There was evidence from service users ‘ plans that service users have good access to doctors and other health care professionals. The inspector met the local doctor during the visit. Service users confirmed that they had good access to chiropodists, opticians and dentists. Medication records on all three units were examined. The majority of records in relation to the receipt, administration and disposal of medication were satisfactory. However in the annex wing of the home, records were not accurate and records indicated that service users, on occasions may not be getting the correct number of tablets. The manager informed the inspector that he would ensure that two staff always check the administration of medication. A requirement relating to this has been restated in the relevant section of this report. Another requirement was issued at the last inspection that written confirmation must be provided for service users who require covert medication. The new forms detail “crushing” of tablets but this form needs to make reference to covert medication. The requirement is restated. Discussions with staff and service users demonstrated that personal care was undertaken in the privacy of service users own rooms. Service users interviewed spoke highly of the time that staff spent with them on an individual basis, and the way their families are included in the life of the home. The inspector particularly noted the way in which the staff team addressed service users, who were often confused and challenging, promoting their privacy and dignity. CLORE MANOR Version 1.10 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 standard(s) 12 and 15 The activities team are to be commended for their continued enthusiasm, creativity and the excellent range of activities arranged for the home. Service users receive a wholesome, appealing and balanced diet. Mealtimes are sociable and stimulating. EVIDENCE: The activities programme for the week was posted at the entrance to the unit, and included varied activities that would appeal to a wide range of interests. Activities available during the week included sessions on arts and crafts, Jewish culture, aromatherapy, knitting club, bingo, discussion groups, visits from PAT dog owners, manicures, card games and tea parties. Service users were very positive about the activities available to them and one service user commented “there is always something going on”. The newly appointed activities organiser was very enthusiastic regarding her role. All service users that the inspector spoke with said the food at the home was very good. One service user commented, “the food here is fantastic, there is a good variety and we are always offered a choice”. The chef has a good rapport with service users and was observed asking their views on how the food was. CLORE MANOR Version 1.10 Page 12 CLORE MANOR Version 1.10 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 standard(s) 16 Service users and their relatives and friends are able to make complaints and these complaints are taken seriously and dealt with in an open and nondefensive manner by the home. EVIDENCE: All service users spoken to said they had no complaints but knew how to complain if they needed to. The records of complaints were examined. Evidence from letters to complainants indicated that the home has dealt with these complaints in a timely and open manner and according to policies and procedures. CLORE MANOR Version 1.10 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 standard(s) 19,20, 22 and 25. The home is well maintained and good systems are in place to ensure service users are safe. The home has appropriate aids and adaptations for service users with mobility problems. EVIDENCE: A tour of the premises indicated that the building is in a reasonable state of repair and newly fitted alarms indicate when confused service users may wander out of the building. This is particularly relevant as the home is situated next to a very busy main road. It was noted that the concrete floor in the food storage area is in need of repair. A requirement has been issued in the relevant section of this report. A requirement was issued at the last inspection regarding the repainting/repapering of various areas of the home. Although this has not taken place as yet and the requirement has been restated, the home is to be completely refurbished in a month after Passover. All bathroom and shower rooms are now functioning. This was a requirement from the previous inspection. Water temperatures in hand basins were randomly tested CLORE MANOR Version 1.10 Page 15 and found to be close to 43 degrees. This was a requirement from the last inspection that has now been complied with. The home is equipped with appropriate hoists and assisted baths to meet the needs of service users who have mobility problems. There are handrails and grab rails in corridors, toilets and bathrooms. A recent occupational therapist’s assessment was available for the home indicating that provision was satisfactory for the needs of service users accommodated. CLORE MANOR Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The ongoing dementia training has increased staff awareness of the problems faced by people with dementia and their families and staff provide a very good standard of care. Staffing levels are appropriate to meet the needs of service users. EVIDENCE: Following a review of staffing numbers at the home, due to increased dependency levels of service users, there are now more staff on duty in the main unit. Staff were observed interacting and supporting service users in a friendly and professional manner. All the service users spoken to during the inspection were very positive regarding the management and staff at the home. One service user commented that she was very happy at the home and that staff treat people like human beings. On the day of the unannounced inspection there were sufficient staff to meet the needs of service users at the home. Staff interviewed showed an excellent understanding of the issues relating to dementia care. CLORE MANOR Version 1.10 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 Service users and their representatives are able to have a say in how their care is delivered and their views about how well the home is doing are recorded and action taken as a result. The home takes the safety of service users seriously and there are good systems in place to monitor the safety of the home and reduce identified risks. EVIDENCE: Jewish Care conducts quality assurance audits periodically in addition to monthly regulation 26 visits. These audits are carried out approximately sixmonthly and action plans are formed accordingly. Service users confirmed that their views on the quality of care at the home have been sought. CLORE MANOR Version 1.10 Page 18 There was documentation available regarding the collection of clinical waste, pest control, installation of the new boilers, servicing of hoists and lifts (and lift insurance). Generally the home has good policies and procedures in place to monitor health and safety compliance. A requirement issued at the last inspection that fridge temperatures in all units be monitored has now been complied with. The kitchen was very clean and contained appropriate, functioning equipment. CLORE MANOR Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x 3 x x 3 x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 3 CLORE MANOR Version 1.10 Page 20 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 9 Regulation 13(2) Requirement Timescale for action 31/05/05 2. 9 13(2) 3. 20 23(20(d) 4. 19 23(2)(b) The registered manager must ensure that accurate records are maintained of the receipt and administration of medication in the home in order to provide a clear audit trail. (Timescale of 01/12/04 not met) This requirement is restated. 31/05/05 The registered manager must ensure that where medication is given covertly this must be first discussed with the family and written confirmation given by the service user’s doctor that this is the only course of action available to ensure the wellbeing of the service user concerned. (Timescale of 01/12/04 not met) This requirement is restated. The registered person must 31/06/05 ensure that repainting/papering of various areas which are worn is undertaken in the corridors on the first and second floors. (Timescale of 01/02/05 not met) This requirement is restated. The registered provider must 31/06/05 ensure that the flooring in the food storage room is repaired. Version 1.10 Page 21 CLORE MANOR RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations No recommendations have been issued at this inspection. CLORE MANOR Version 1.10 Page 22 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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. 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