Inspection on 13/08/08 for Clyde House

This inspection was carried out on 13th August 2008.

CSCI found this care home to be providing an Good service.

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

Clyde House 13/09/06

Clyde House 22/11/05

Clyde House 21/06/05

Clyde House 07/10/04

Clyde House 21/06/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Clyde House 258 Sedlescombe Road North St Leonards On Sea East Sussex TN37 7JN Lead Inspector Debbie Calveley Unannounced Inspection 13th August 2008 07:45 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 Clyde House DS0000013974.V369073.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. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clyde House Address 258 Sedlescombe Road North St Leonards On Sea East Sussex TN37 7JN 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) 01424-751002 01424 757900 clydehouse@new-meronden.co.uk www.newcenturycare.co.uk New Century Care Limited Care Home 48 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (48), Physical disability (48) of places Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The maximum number of service users to be accommodated is fortyeight (48). Service users must be older people aged sixty-five (65) years or over on admission, or fifty (50) years or over on admission if they have a physical disability. The maximum number of service users with nursing needs to be accommodated at Clyde House is thirty (30) excluding the Tay Unit. A maximum number of eighteen (18) service users with a dementia type illness, aged fifty-five (55) years or above on admission to be accommodated on the Tay Unit. One named service user with nursing needs to be accommodated on the Tay Unit. 13th September 2006 Date of last inspection Brief Description of the Service: Clyde House is a large building situated in a residential area of Hastings, close to local amenities and public transport. It is owned by New Century Care Limited (NCC Ltd) and is part of a group of homes situated in East Sussex. The home is set out over three floors and is registered to provide care for a maximum of 48 residents. The lower ground floor, known as the garden floor, has access to the garden and the middle floor, on the ground floor from the main entrance, has the main lounge and dining room. Thirty residents requiring nursing care can be accommodated on these two floors, whilst the top floor, known as the Tay Unit), is registered to accommodate eighteen residents with a dementia type illness. A shaft lift enables easy access to all parts of the building and all areas are accessible for those with limited mobility. There are hoists and bath hoists as well as grab rails and disability aids in the bathrooms and toilets. A large garden to the rear and communal areas on all floors provide relaxation areas for residents and their visitors. There is a parking area to the front of the building for up to approximately ten cars. The home welcomes prospective residents or their representatives to view the premises, discuss their needs with the Registered Manager and spend time with the staff and residents. Weekly fees range from £511 - £700 as at 13/8/08, for full nursing care. The fees do not include hairdressing, chiropody, manicures and any sundries, such as newspapers or personal shopping: these are charged as extras. Information about the service is available on the organisation’s website (New Century Care Limited) and from the home’s Manager. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Clyde House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 6.5 hours on the 13 August 2008. There were forty-six residents living in the home on the day, of which five were case tracked and spoken with. During the tour of the premises eight other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Four members of care staff and the relief cook were spoken with in addition to discussion with the manager, deputy manager and area manager. Telephone contact was made with visiting professionals following the visit The information received verbally and from surveys has been incorporated into this report. At the time of writing this report seven staff and four service user surveys were received. An Annual Quality Assurance Assessment was received from the Manager completed in full prior to this key inspection. What the service does well: There is a comprehensive Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. It would be beneficial for if there was more detailed staff training information that would assure prospective residents and their families that their needs could be met. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 6 Residents confirmed that they were visited by the manager prior to admission to the home and two stated they had been invited to visit the home to see if they liked it enough to live there. Comments received included ‘ the deputy manager was most helpful’ ‘ I visited the home and liked the people I met’. The menus evidence a well thought out balanced diet with a varied choice of food in line with resident’s preferences. Quality assurance systems are in place, which enables the service to monitor and improve their service. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably qualified staff working in the home. The atmosphere of the home is pleasant with good interaction seen between residents and staff. Comments received included ‘ lovely caring staff, very supportive’. ‘ Wonderful care, very kind staff’ ‘Would recommend the nursing home’. There is a robust recruitment process in place to protect the residents. Clyde House provides a clean, safe and well-maintained environment, which is appreciated by the residents and their relatives. Comments regarding Clyde House were generally positive and included: ‘I have been here for a long time and like it’ ‘ I haven’t been here long, but its quiet and peaceful, I am comfortable’ Staff comments included ‘Happy in my work at Clyde House’ The response to what the home does well include ‘ The residents have lots of extra treats and are happy and contented’ ‘ the staff team are very kind and hardworking’. What has improved since the last inspection? What they could do better: Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 7 There is a need to ensure that equipment in use for residents are kept clean and hygienic. Areas of the home identified as having an offensive odour need action taken to eliminate the odours. 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. Clyde House DS0000013974.V369073.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 Clyde House DS0000013974.V369073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission. EVIDENCE: There is a range of well-documented information about the home and the services it provides. The home has a comprehensive Statement of Purpose and Service Users Guide and copies of this are available along with the last inspection report and a copy of the homes terms and conditions of residency in the front entrance area. Residents spoken to were clear on the service provided by the home and costs involved. A recommendation of good practice is to include the training undertaken by the staff. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 10 The registration certificate is clearly displayed and was found to be accurate at the time. The last three admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and provide a clear assessment of prospective residents care needs. These are completed by the manager or a senior nurse and discussion with the manager confirmed that these are used to ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. Prospective residents’ are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. Social care professionals spoken to confirm that pre admission assessments are always completed and that these were completed promptly and efficiently. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses and carers employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for dementia. Trial visits to the home can be arranged. The manager confirmed that residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. People can visit Clyde House for respite care and emergency admissions are supported by a detailed policy and procedure. Intermediate or rehabilitative care is not provided at Clyde House. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provide a good framework for the delivery of care, which give clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Procedures and practices in the home allow for the safe administration of medicines and on the whole the privacy and dignity of residents to be promoted. EVIDENCE: The care documentation pertaining to five residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessments, personal histories and risk assessments. The documentation evidenced regular review and that the resident or a family member is consulted and included in the review. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 12 The health needs of residents were appropriately risk assessed and provided guidance for staff to follow so as to provide a consistent approach to meeting the identified needs. The condition of residents’ skin is assessed and monitored, any pressure areas are recorded and if a sore develops the treatment and outcome is documented. The Manager confirmed that at present there are no residents at present with pressure damage. The organisation have a tissue viability nurse that support the staff. The home staff follow the National Institute for Clinical Excellence (NICE) guidelines for pressure area care. Resident’s dependency and nutritional needs are also assessed and the risk of falling is identified and steps taken to prevent falls. There was evidence to confirm that carers are recording the care provided, and when spoken to said that they read and understood the plans of care, although having time to read them could be difficult at times. Staff receive a report on each resident daily and felt that their views were taken into account when planning resident’s care. The chiropodist visits the home and arrangements are made for residents to see a dentist or optician as needed. Where possible residents remain registered with their own GP or they register with a GP of their choice. The clinical room is located on the lower floor; it is kept locked at all times. There are trolleys used when dispensing medication, the trolleys were clean and well organised. The small clinical fridge is kept locked and temperatures of the room and fridge are recorded daily to ensure safe temperatures for medications. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. The systems for recording and checking controlled drugs were found to be thorough. The Medication Administration Charts (MAR) were found to be competently completed. The dating of the identification photographs of residents was discussed as good practice. There are policies and procedures in place for supporting residents that wish to self-administer their medication. At present there are no residents who wish to self medicate. Staff were seen to be respectful and considerate to all residents and visitors, whilst attending to their needs. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. Clyde House DS0000013974.V369073.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): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time matches their expectations, choice and preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: The activities provided in the home have been well received and enjoyed by the majority of residents that were spoken to. The Activity Co-ordinator has a good understanding of the residents needs as she also works as carer. Staff confirmed that the activities in the home are a great benefit to residents and that celebrations are held regularly for special occasions including birthdays. Residents on the Tay wing join the other residents for activities. The activity co-ordinator discussed the trips out that had been enjoyed and the trips planned for the future. She organises an activities programme that includes some group events but also visits residents who prefer to stay in their rooms and the home celebrate special occasions such as birthdays and Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 14 anniversaries. Activities are publicised through a monthly newsletter circulated to all residents and relatives; it is also available in the main entrance for visitors. There is also a trolley service that is taken round the home, which allows residents to choose chocolates, toiletries, cards and other items, encouraging and supporting residents to be independent. Discussions with residents confirmed that they joined in activities only if they chose to do so; some residents prefer their own company and often spent their time in their own rooms. Resident’s rooms were found to be individual and personalised and each resident has their preferred term of address recorded in their care documentation and this preference was respected. Residents were seen to have their choices respected through out the day with decisions being responded to. Visitors spoken to were all happy with the visiting arrangements and how staff who were said to be ‘very welcoming’ received them. The breakfast and mid day meal was observed and was seen to be organised and well managed ensuring that those residents needing assistance were given time and able to have the assistance that they needed in an unrushed manner. It was confirmed that residents had a choice at lunchtime, which included a vegetarian choice. Those residents saying they did not like the main choice were seen to have alternatives provided that they did want. Menus are used and circulated the day of the meals being provided and records are kept on what food is eaten by each resident. All feedback about the food was complimentary and comments included ‘excellent choices’ ‘I have choices in the meals and the meals are good’ ‘ the chef visits me to discus the meals, he’s very good’. The dining area is pleasant and well furnished with natural light, menus displayed on each table. Residents were also observed sitting in the lounge and in their rooms enjoying their meal. Staff were seen to be following good practice when serving and distributing the meals. The meals provided looked appetising and were served in a manner that ensured it looked attractive. The kitchen was clean and well organised; the head chef was on holiday and a relief cook in place. She demonstrated a good knowledge of the specialised meals required and the residents’ personal tastes. The home work with the ‘Safer Cooking Better Business’ book which was seen to be completed daily. Clyde House DS0000013974.V369073.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): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and the Service Users Guide. A system of recording complaints was demonstrated to the inspector during her visit to the home. The home has received two complaints since the last inspection, which were fully investigated using the homes complaint procedure. Relatives and residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. There have been two safeguarding investigations in the past year of which both were fully investigated and not upheld. Clyde House DS0000013974.V369073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clyde House provides a comfortable, clean and safe environment for those living there and visiting. Residents and their families are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: Clyde House is situated in a residential part of St Leonards on Sea and is convenient to local shops and bus services. The home provides accommodation over three floors, all of which can be accessed by stairs or a lift. There is a good size garden to the rear that can be reached via some resident’s rooms, a door on the lower ground floor (known as the garden floor), or by steps from the conservatory on the ground floor. On the ground floor there is a dining room and a lounge, both of which lead into the large Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 17 conservatory overlooking the garden. The first floor is known as the Tay wing and is specifically for up to eighteen people who have a dementia type illness. Tay unit has its own lounge/dining area, clinical room and sluice. The bedrooms are attractively furnished with an ensuite facility. The home throughout is attractively and comfortably furnished and provides a spacious environment for the people who live there. Residents who expressed an opinion spoke positively about the home, many have decorated their rooms with their own possessions, pictures and ornaments. There are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Water temperatures are controlled and monitored monthly and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Radiator guards are in place throughout the home and windows are appropriately restricted. Polices and procedures for infection control are in place and are updated regularly. The home was clean and in the main free from offensive odours on the day of the inspection. Areas identified as malodorous are being monitored and dealt with by the home. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. The laundry area was found clean and safe. The home provides a good laundry service. The ground floor sluice equipment was in need of deep cleaning to prevent cross infection. Clyde House DS0000013974.V369073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures they are aware of their roles and are able to provide the support and care the resident’s need. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Care staff spoken with said that the levels of staff on duty were sufficient to give the care required; they also said that the trained staff always helped out. Most of the residents also confirmed that they had no complaints regarding the amount of staff. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 19 The home employ twenty-three care staff, and approximately 78 have or are currently studying for the National Vocational Qualification (NVQ) level 2. It is the organisation’s policy that any new care staff are recruited with a view to them undertaking the ‘Skills for Care’ Induction and Foundation, which links into the NVQ level 2 (if they do not already have it). Files seen confirmed this. Staff spoken with said that training opportunities at the home are good and they are well supported by the senior staff and the manager. Staff and the training list seen confirmed that compulsory training such as manual handling, adult protection, first aid and fire safety are being undertaken on a regular basis. Specialist training such as dementia care, Parkinsonism and diabetes are undertaken to ensure that the staff have an understanding of residents health needs. The manager has a training matrix, which track and identify the training needs. Clyde House DS0000013974.V369073.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of Clyde House is good with effective systems in place to protect residents. EVIDENCE: The registered manager has worked in the home for nine years; she is a level 1 registered nurse and has completed the Registered Managers Award (RMA). The manager has the experience and qualifications to run the home effectively. The deputy manager completes the internal management team and an area manager who visits the home at least once a week supports the home. Staff and residents said they felt supported by the management structure of the home, that the manager was ‘approachable and fair’, ‘she is always available to talk to if needed’. Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 21 The quality assurance systems in the home include questionnaires sent out annually to residents and relatives following admission to the home. These are analysed and presented in easy to read graph format, which are laminated and the results are publicised to the residents and displayed with the other information in the main entrance. The introduction of this formal quality assurance and quality monitoring systems has enabled the management to objectively evaluate the service and ensure it is run in the residents best interests. The quality assurance results have been audited and action taken to address any suggestions of improvement. Monthly internal audits are also undertaken and a senior manager undertakes a monthly, unannounced visit to inspect the premises and speak with residents and staff, as required under Regulation 26. There are a few residents at present who are responsible for their own finances; relatives and solicitors support the majority, while the home does not handle the financial affairs of residents. There is a float available, where the home pay for sundries and then the amount is added to the monthly bill with the relevant receipt. Staff supervision was discussed and staff supervision is in place for all staff. Staff spoken with confirmed that they receive supervision and a plan of the year’s supervision sessions was seen. The supervision notes were available for inspection. The Annual Quality Assurance Assessment was completed in full on the 19.05.08. It confirmed that the statutory training is undertaken and external courses accessed to meet the resident’s health needs. The manager maintains a training matrix to monitor that all staff have their mandatory updates. The Accident book for the home was viewed and all incidents and accidents were found fully recorded and detailed appropriate action taken. Good practice was observed throughout the inspection in respect of promoting the safety and well being of the residents. Clyde House DS0000013974.V369073.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP26 Regulation 23 Requirement That the registered person ensures that all the equipment used for residents is clean to prevent cross infection. Timescale for action 13/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Clyde House DS0000013974.V369073.R01.S.doc Version 5.2 Page 25 - 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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