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Inspection on 11/05/06 for Clumber Court Care Centre (Care Home)

Also see our care home review for Clumber Court Care Centre (Care Home) for more information

This inspection was carried out on 11th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A kind and caring ethos is prevalent throughout the home and staff were observed to treat service users with respect. Service users spoken with were very happy with life within the home and care received. Staff spoken with were knowledgeable and able to discuss the core values and principles. It was evident that service users are enabled to make choices with regards to their lives and how they spend their time in the home and their personal preferences are regarded.

What has improved since the last inspection?

There have been several improvements since the previous inspection. Risk assessments have undergone improvement ensuring staff are working towards ensuring service users are protected. Service users reviews have made a slight improvement and significant changes are noted in service users plans of care to ensure consistency is maintained. The medicine policies and procedures have improved and a relevant disposal contract is now in place, ensuring service users are protected. Appropriate records with regards to cleaning are now available to demonstrate daily cleaning is taking place in the kitchen thus ensuring service users are protected. Staff training continues to develop and eleven staff have now been trained in first aid, it is the intention to cascade learning to other staff ensuring service users are protected. Service users finances have been restructured to demonstrate the amounts in safe keeping more clearly, thus protecting service users finances. Emergency lighting is now tested on a monthly basis ensuring service users are protected.

What the care home could do better:

To ensure all highlighted needs are fully documented in the plan of care to ensure service user needs are fully met. Whilst it is acknowledged that risk assessments have made an improvement further development is still required to ensure service users are fully protected. Service users reviews are required to continue to develop to ensure they are service user focussed and reflect care and condition. The acting manager has now been in post for four months, therefore a decision as to applying to become the registered manager is now required to ensure the home is run by a person who is fit to be in charge. It is recommended that the quality assurance systems are further developed to include questionnaires for service users and relatives to demonstrate that the home is being run fully in the best interests of service users. To ensure equality and diversity is fully acknowledged and respected it is recommended that a life story for each service user is undertaken to assist in this process.Whilst the process of recruiting a new activities coordinator is taking place it is recommended that further consideration is given to those service users who wish to undertake additional activities to ensure their needs are fully met.

CARE HOMES FOR OLDER PEOPLE Clumber Court Care Centre (Care Home) Bolham Lane Retford Nottinghamshire DN22 6SU Lead Inspector Karmon Hawley Unannounced Inspection 11th May 2006 10:00 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 Clumber Court Care Centre (Care Home) DS0000024636.V288111.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. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clumber Court Care Centre (Care Home) Address Bolham Lane Retford Nottinghamshire DN22 6SU 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) 01777 700823 01777 705143 clumber.court@ashbourne-homes.co.uk Ashbourne Homes Limited Care Home 64 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (64), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (64) Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Clumber Court Care Home was established in 1993 and is now owned by Southern Cross. Clumber Court is situated around a mile from the lively market town of Retford and enjoys a pleasant, picturesque and quiet location alongside the river Idle. Due to limited transport links the home has access to a car and accommodates relatives who may have difficulty with transport. Clumber Court is built on two levels and caters for the care of older people and offers specialist residential and nursing care for up to 64 older people with dementia type illness. There are sufficient seating areas throughout the building and a pleasant secure garden for service users to enjoy. Accommodation is provided in single rooms and service users are enabled to bring in personal possessions in order to personalise them. The current weekly rates for social service placements for residential care are: single room £334, ensuite room £339. For nursing care single £438 and ensuite £443. The current weekly rates for privately funded service users is residential single room £360 and ensuite £400. For nursing care single room £485 and ensuite £495. These rates and information about the home is offered to prospective service users and relevant others on initial enquiry. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of four and a half hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Seven service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The acting manager assisted in the inspection process and three members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: A kind and caring ethos is prevalent throughout the home and staff were observed to treat service users with respect. Service users spoken with were very happy with life within the home and care received. Staff spoken with were knowledgeable and able to discuss the core values and principles. It was evident that service users are enabled to make choices with regards to their lives and how they spend their time in the home and their personal preferences are regarded. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: To ensure all highlighted needs are fully documented in the plan of care to ensure service user needs are fully met. Whilst it is acknowledged that risk assessments have made an improvement further development is still required to ensure service users are fully protected. Service users reviews are required to continue to develop to ensure they are service user focussed and reflect care and condition. The acting manager has now been in post for four months, therefore a decision as to applying to become the registered manager is now required to ensure the home is run by a person who is fit to be in charge. It is recommended that the quality assurance systems are further developed to include questionnaires for service users and relatives to demonstrate that the home is being run fully in the best interests of service users. To ensure equality and diversity is fully acknowledged and respected it is recommended that a life story for each service user is undertaken to assist in this process. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 7 Whilst the process of recruiting a new activities coordinator is taking place it is recommended that further consideration is given to those service users who wish to undertake additional activities to ensure their needs are fully met. 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. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 8 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 Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to moving in to the home. EVIDENCE: A trained member of staff visits prospective service users in the community prior to admission and completes an assessment. The assessment covers the requirements of this standard. Service users and relatives may also visit the home prior to making a decision and meet and discuss any issues with staff. Clumber Court Care Centre (Care Home) DS0000024636.V288111.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in a plan of care, however needs may not be fully met due to these not being recorded in the plan of care or reviews being service user focussed to reflect care and condition. Service users may also be at a degree of risk due to further development required with regards to risk assessments. Service users health care needs are fully met. Service users are protected by the homes medication policies and procedures. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users undergo various assessments such as the activities of daily living, recreational and social needs, manual handling and aids required, pressure area care, falls, mental health and nutrition. Information gained underpins the plan of care. Care plans in place were personalised and reflected choices and preferences. Care plans were a mixture of pre printed and hand Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 11 written. The hand written care plans with regards to pressure area and wound care following surgery were very in depth There was evidence to demonstrates that care plans are rewritten to reflect changes as needed however within one case file where a crash mat was in place this had not been mentioned in the service users plan of care and where another had displayed challenging behaviour there was also no plan of care in place. Risk assessments were in place for the majority of risks highlighted however there was no risk assessment in place were a service user was undergoing oxygen therapy, where one had presented with challenging behaviour and another may have been at risk of falls. There was evidence to demonstrate that the multidisciplinary team are accessed as required, as are specialist services. There was documentation available with regards to a personal life story of service users, however in all files observed this had not been completed. There was evidence that the multidisciplinary team are liaised with and appropriate equipment and aids are available. There was also evidence to demonstrate that specialist services such as the optician, and chiropodist are accessed and liaised with as required and service users have access to national health entitlements. Service users spoken with stated that their needs were met and they were happy with care received. Staff were able to discuss service users needs and the core values and principles. Relevant policies with regards to medicines are in place; a contract with regards to the disposal of medicines has now been implemented. Service users medication was checked against the prescription, which corresponded. A air conditioning unit has been placed in the treatment room, which is on at all times ensuring the room temperature is now at an acceptable level. Staff who administer medication have undertaken training with this regard. Staff are instructed during the induction programme and throughout their working time at Clumber Court on the importance of maintaining service users privacy and dignity. One service user spoken with stated that their privacy was respected at all times. All consultations are carried out in service users own rooms and visitors may be received in private should they wish. Clumber Court Care Centre (Care Home) DS0000024636.V288111.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the service. Service users are enabled to find the lifestyle experienced in the home matches their expectations and preferences and satisfies their need, however further consideration with regards to activities for some service users would be beneficial to ensure needs are fully met. Service users are enabled to maintain contact with relevant others as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings. EVIDENCE: Each unit within the care centre operates independently and encourage a flexible way of living. Service users spoken with stated they may choose when they rise and retire to bed and can also choose what they do during the day. Two service users spoken with stated that they are free to do as they wish and staff do not interfere. All service users undergo an assessment with regards to social and recreational needs; however there is currently no activities coordinator employed, an advertisement for this position has been placed. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 13 Staff in the mean time are carrying out activities as able, staff spoken with were able to substantiate this. Two service users spoken with stated they were happy and content with this and there was enough for them to do whereas one service user expressed boredom and the wish to carry out more activities, the manager was made aware of this desire. Outside entertainment continues and activities such as musical movement and singers are available. The home currently has links with the Alzheimer’s society and is working with these to develop activities within the home. Meals are at a set time, however some flexibility is facilitated. A choice is offered which service users substantiated and they stated food was nice. Service users may choose where they take their meals. A regular church service is offered within the home and three service users also attend church in the community. There are no restrictions imposed upon visiting and if privacy is required this is available within service users own rooms and among the various small seating areas throughout he home. One service user spoken with stated that their family visits them regularly and they are made welcome, they also stated that their family takes them out. If a service user chooses not to see a visitor this would be dealt with sensitively and appropriately. Service users personal allowances are in general dealt with by their relatives, and a small amount kept at the home if desired, however should the need arise social workers or advocates would be approached. Service users may bring in personal possessions, which was evident during the tour of the home as service users rooms were personalised. Service users undergo a nutritional assessment and specialist needs are catered for if required, there was evidence to demonstrate that the dietician is liaised with when necessary. Staff were able to discuss supplements and how these are administrated to service users. A four weekly menu is followed, which demonstrates that a wholesome and appealing diet is offered. There was also evidence that choice is given at each mealtime and two service users were able to substantiate this and stated that food is of a good standard. The appropriate records with regards to the kitchen were available and met the requirements of this standard. Clumber Court Care Centre (Care Home) DS0000024636.V288111.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality rating for this outcome area is good this judgement has been made using evidence available including a visit to the service. Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: There have been no complaints received since the last inspection. The complaints procedure is made available to service users and relatives. There have been changes in the main entrance and a box of information is available for visitors, included if the methodology of how to make a complaint should the need arise. The acting manager also carries out surgeries on a regular basis with relatives so they may discuss any concerns they may have of spend the time discussing their relatives care. Service users and relatives are consulted with prior to any changes occurring in the home. There was evidence of this available as the acting manager has written to relatives and arranged a meeting in the near future with regards to moving service users within the home to enable needs to be fully met. Staff spoken with were able to discuss how complaints would be dealt with should they be received. All service users spoken with expressed hey were very happy and settled in the home and had no complaints. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 15 There are relevant policies and procedures in place with regards to the protection of vulnerable adults. Staff spoken with were able to discuss these issues. Prior to this inspection one referral had been made to the protection of vulnerable adults team. This incident has been fully investigated and resolved with no blame apportioned to the home. The acting manager has spent time supervising staff and discussing these issues. 73 of staff have received training with regards to residents welfare and 8 members of staff have attended a course on dementia care needs. All staff employed have a satisfactory criminal bureau record check in place. Service users spoken with expressed they felt safe and secure. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality rating for this outcome area is good this judgement has been made using evidence available including a visit to the service. Service users live in a safe, clean, pleasant and hygienic environment, which is well maintained. EVIDENCE: There is a maintenance man employed who carries out all maintenance and decorating within the home. The care centre is purpose built and has the required adaptations, there is a lift offering access to the upper floor. There are various seating areas within the home and access to the secure garden from the ground floor. There are ample domestic staff employed to maintain the cleanliness of the home. During the tour of the home all areas were clean, tidy and well presented. The laundry room is situated on the upper floor and was well Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 17 maintained, had all required equipment and complied with requirements. Staff are have undertaken a distance learning course in infection control. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the home. The numbers and skill mix of staff meets service users needs. Staff are working towards ensuring service users are in safe hands at all times. Service users are protected and supported by the homes recruitment policies and practices. Staff are working towards ensuring they are fully trained and competent to do their job. EVIDENCE: The duty rota was observed which demonstrated that sufficient staff are employed to meet service users needs. Skill mix is taken into consideration when planning the off duty and additional staff are available at busy times during the day. Staff spoken with stated that there were sufficient staff however it would be beneficial if at times more were available. Service users spoken with stated that staff were available to assist them to meet their needs. One member of staff has attained the national vocational qualification level two and one has attained level three. There have been problems experienced by the staff in the home with regards to an assessor. Several members of staff had commenced and were working towards to the qualification however the contract with the home was discontinued, therefore the acting manger is looking into new sources that may be able to supply a service. The induction Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 19 programme remains intense and there was evidence of staff completing and working towards completing this training. Four staff files were observed and contained all the required documentation to meet this standard. Staff training continues to develop and a number of staff have undertaken a course in infection control, first aid, fire and dementia awareness. As the home has now been taken over by Southern Cross additional training has been introduced, the acting manager is yet to implement this. All senior staff have been issued with the complete set of policies and procedures with regards to clinical practice to ensure all staff are aware of the requirements. There was evidence of this available to demonstrate staff had begun working through these packs to ensure they have the required knowledge and skill. Each member of staff has an individual training plan and there was evidence to demonstrate that training is at a satisfactory standard. Staff are paid for all training courses attended. Staff spoken with stated that they felt supported in their training and substantiated that it was at a good standard. Staff spoken with were able to discuss the core values and principles and the whole person needs of service users. One service user spoken with stated that she was well looked after and staff were very nice. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the service. Service users live in a home, which is run and managed by a person who is of good character and able to discharge her responsibilities, however a decision is to be made as to whether to apply to become the registered manager is now required to ensure the home is run by a person fit to be in charge. The home is run in the best interest of service users, however this may be developed further if formal questionnaires are circulated to service users and relatives. Service users personal finances are safeguarded. Whilst the health, safety and welfare of service users are promoted and protected, risk assessments require further development to ensure safety of service users is not compromised. EVIDENCE: Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 21 The acting manager is a registered nurse and has been in post for four months; previous to taking up this post she was the manager of another home within the company. She has worked at Clumber Court before as a senior sister trainer and care manager and has attained a Certificate in Management Studies. She was able to demonstrated knowledge and skills in regards to the management of the home and service users needs. Staff spoken with spoke highly of the manager and stated that the home is more settled and improvements have been made. Service users expressed they were happy with the way in which the home was managed. Monthly audits are carried out and cover the following, health and safety, quality care, infection control, activities, customer care, medicines, food, training and hotel services. Statistics are then send to the regional office and action plans are devised if required. Although no formal questionnaires are sent to service users or relatives at present time is spent both informally and formally with service users if able and relatives by means of the surgeries and general meetings. Service users accounts are now individualised in the sense that individual wallets are in use, therefore making the distinction between the amounts kept in the bank and in the home. Receipts were available for transactions and two members of staff had signed these. A central bank account continues to be in use due to the difficultly in opening individual accounts, however the administrator is currently looking into alternative ways this may be dealt with. Receipts were kept for transactions and two signatures were obtained. Four service users accounts were checked and corresponded with the accounting sheet. Relevant servicing, maintenance checks and contacts were observed to be in place. Accident logs were monitored and statistics sent to head office on a monthly basis. All staff employed have a criminal records bureau disclosure check in place, all registered nurses identification numbers were observed to be checked on a monthly basis. Risk assessments continue to require development. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION XStandard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 23 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 Standard OP7 Regulation 13(4,c) Requirement Timescale for action 11/06/06 2 OP7 15 3 OP7 15 4 OP31 8(a) To fully protect service users it is required that appropriate individual risk assessments and management plans are in place. This has been partly met; further development is now required to ensure service users are fully protected. Service users reviews are 11/07/06 required to be service user focussed to reflect care and condition. This has been partly met; reviews now need to be developed further to ensure service users needs are fully met. Service users highlighted needs 11/07/06 are required to be set out in an individual plan of care to ensure their needs are fully met. The acting manager is required 11/07/06 to apply to become the registered manager to ensure a person fit to be in charge runs the home. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 24 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 3 4 Refer to Standard OP7 OP12 OP28 OP33 Good Practice Recommendations To ensure equality and diversity is further enhanced to complete life stories for individual service users. To consider service users needs with regards to further activities. 50 of care staff are trained to at least NVQ level 2. To issue service users and relevant others with quality assurance questionnaires to complement the quality assurance system. Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clumber Court Care Centre (Care Home) DS0000024636.V288111.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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