Inspection on 13/09/05 for East Clune Care Home

This inspection was carried out on 13th September 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

East Clune Care Home 29/10/08

East Clune Care Home 09/11/06

East Clune Care Home 24/02/06

East Clune Care Home 23/03/05

East Clune Care Home 09/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE East Clune Care Home West Street Clowne Chesterfield Derbyshire S43 4NW Lead Inspector Sue Richards Unannounced Inspection 13th September 2005 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 East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service East Clune Care Home Address West Street Clowne Chesterfield Derbyshire S43 4NW 01629 580000 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) Derbyshire County Council Susan Steadman Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2005 Brief Description of the Service: East Clune provides personal care for up to 30 older persons, both female. It is located within the village of Clowne, which lies to the north east of Chesterfield. Accommodation is arranged over two floors and there is a choice of lounge and dining space. There are 22 single and 4 double bedrooms, with one of the single room having an en suite. There is a choice of bathrooms and toilet facilities, which are suitably equipped. There is a central kitchen and laundry with a separate laundry area for service users to access who may wish to launder personal items. Access to outside garden areas is level and provides seating. The Manager has the support of a team of deputies, care and hotel services staff and also external management arrangements of Derbyshire County Council. One of the communal rooms is accessed by a small group of older persons for the purpose of day care. Service users who live in the home are able to access activities there if they so choose. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on the environment, staffing arrangements and management systems for the home, including that relating to the admissions process. Methodology included discussions with the manager and staff on duty and a number of service users accommodated. Records were also examined in relation to the inspection process and a tour of the building was undertaken. What the service does well: What has improved since the last inspection? Approval has been gained for the provision of a walk in shower with work due to commence on this and information is now available for service users and their representatives in relation to access to advocacy. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 6 Records kept in the home in respect of each staff employed there were in accordance with requirements. Approaches to the collation of information in respect of staff training needs were being developed, together with the ongoing audit of the quality of care and service provision by way of satisfaction surveys formulated for both service users and staff. (A small number of requirements were identified at the previous inspection for this service (March 2005) relating to service users care plans and recorded needs assessments. These areas were not inspected on this occasion – they will be inspected during the next inspection for this service to be undertaken later in the inspection year 2005-06). What they could do better: Please contact the provider for advice of actions taken in response to this inspection. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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 East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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): 4&5 Service users and their representatives do have some opportunities to visit and assess the quality, facilities and suitability of the home. However, current management arrangements for the admission of service users to the home for short-term care (including assessment, emergency and respite) are not wholly satisfactory. There are not clear criteria or defined tools in place in the home to enable the manager and senior staff to have proper control over this process. EVIDENCE: Discussions took place with the manager and staff regarding the admissions process for the home, particularly in respect of the significant number of service users admitted for short term care, including emergency admissions, assessment and respite care. Between January and June a total of 48 service users had been admitted to the home for short-term care, with six being accommodated at the time of the inspection. Discussions included that relating to the arrangements and criteria for admission under those circumstances and the potential impact on existing East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 10 long term service users accommodated, including staffing and workload considerations. The Statement of Purpose for the home was examined in relation to this and also the home’s written admissions policy. Service users spoken with did not express any negative views in relation to the impact of short term care arrangements as they perceived this to be socially stimulating given that the majority of persons admitted were from the local community and therefore relationships, friendships and community links were often previously established. This was felt by service users to be positive in relation to the purpose of the home, including by service users admitted under short-term care who may later choose to live in the home long term. Service users advised that staff worked hard and provided them with the help and support they required. Staff were supportive of short term care admissions in principle and felt this to be an important part of the culture of the home, however, expressed some concerns, that given the volume of such admissions, that there was a danger that the purpose of the home would be lost. The Inspector supports this view. Feelings of helplessness and confusion was expressed by the manager and senior staff, who did not feel in control of the process, particularly in respect of not having clearly defined boundaries or a framework to work to, including an active review process supported by the local authority, who determine admissions to the home. The boundaries in relation to such admissions were not clear in respect of the home’s recorded admissions policy, giving no clear criteria for these and also from information provided within the home’s statement of purpose, which the Inspector examined. There was also no clear measure of the individual dependency needs of existing service users. All of which would provide a basis for staff to assist in determining the home’s ability and capacity to admit further service users. At the previous inspection carried out in March 2005 the Inspector observed that there were deficits in terms of the lack of fully completed needs assessment information and care planning information for service users admitted initially by way of short term care arrangements. (The Inspector did not inspect care needs assessment/care planning information on this occasion, but will assess this at the next inspection for this service to be carried out later in this inspection year 2005-06). East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standard in this section were not assessed on this occasion. EVIDENCE: East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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 standards in this section were not assessed on this occasion. EVIDENCE: East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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 the following standard(s): Service users knew how to complain and were confident that any concerns they raised would be acted on and taken seriously. There were suitable systems and arrangements in place to promote the protection of service users from abuse. EVIDENCE: There is a complaints procedure in place for the home, which is openly displayed. Additional written information is provided for service users regarding how to complain. Service user spoken with knew how to complain, but felt that the manager and staff listened to any concerns they voiced and that matters were usually promptly dealt with without the need to make a formal complaint. There was a recognised system in place for the reporting and recording of complaints. Staff spoken with was conversant with the procedure and records examined were satisfactory. There were no complaints recorded since the previous inspection. There were arrangements in place to enable service users to vote and information was promoted regarding access to advocacy services. Staff spoken with knew how to respond and what action to take in the event of any allegation or suspicion of the abuse of a service user and there was East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 14 adequate policy guidance in place in relation to this. All had undertaken relevant training in respect of abuse awareness and adult protection procedures and records examined reflected this. The arrangements for the management and handling of service users monies were discussed with senior staff responsible and examined, including storage, records and policy guidance. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. The home is generally well maintained, clean, comfortable and suitably furnished and equipped. The registered persons had not ensured full compliance with the Fire Officer’s recommendations from his inspection in March 2005. EVIDENCE: A full tour of the building was undertaken. All communal areas were inspected, and a number of service users bedrooms. Areas of the home seen were clean, comfortable, well furnished and equipped and generally well maintained. Heating, lighting and ventilation was also satisfactory. Service users spoken with felt the home was well kept and were satisfied with their own rooms. The Fire Officer had visited the home in January and March 2005. The recommendation made by him during was not complied with as at 13.09.05. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 16 The Inspector raised this as a serious concern in writing, which was handed to the manager during the inspection detailing action to be taken. A separate written letter has also been forwarded to the responsible individual detailing the same. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The arrangements for the staffing of the home, including recruitment, induction and training were generally satisfactory. However, the minimal staffing arrangements during the evening and at night require consistent review and careful monitoring. EVIDENCE: The dependencies and needs of service users were discussed with the manager and staff. There was no formal assessment tool used to determine service users dependencies, although the manager advised that dependencies on the whole were medium, but expressed a general view that service users were being admitted with higher levels of need over recent months than historically. The arrangements for staffing the home were discussed and duty rotas examined. These were generally satisfactory with the provision for some flexibility to provide additional staff. However, rotas indicated that during the period of around 4 pm to 10 pm there were generally a total of three carers on duty for 27 service users with 2 provided at night. Discussions with staff and service users indicated that at times this caused some difficulties in terms of staffs’ ability to respond to calls for assistance promptly. Service users spoken with felt that staff responded to the best of their abilities and confirmed that they did not wait for unacceptable periods of time for assistance and were not dissatisfied with their care. The Inspector discussed with the manager the need to review and monitor this in accordance with service users East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 18 dependencies/care needs and considering the potential safety of service users and the impact of any further or emergency admissions. A staffing survey was in the process of being undertaken, which included invited responses from staff as to their working/workload arrangements. In addition a survey was also being undertaken of service users and their satisfaction as to the care and service provision they receive. The arrangements for recruitment, induction and training (including arrangements for access to NVQ training) were discussed with the manager, senior staff and some care staff and records were examined in relation to these. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 19 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, 32, 33, 34, 35, 36, 37 & 38. Overall there were satisfactory arrangements in place to promote the health, safety and wellbeing of service users and staff (with the exception of the outstanding requirement made by the Fire Officer) and to ensure that service users rights and interests are safeguarded. EVIDENCE: The registered manager provided information regarding training undertaken by her over the last 12 months. The Inspector also discussed the arrangements for promoting communication and direction in the home with the manager and also with individual staff. These included established meetings, individual and ongoing supervision, handovers, the provision of information for staff, including relevant policy and procedural guidance, staff job descriptions and the arrangements for records and record keeping. Records relating to these were also inspected and were satisfactory. Many policies and procedures as East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 20 per Derbyshire County Council’s guidance had not been reviewed for significant time periods. Methods established for the purposes of quality monitoring in the home were also discussed, including environmental health and safety audits, monthly visits conducted by a representative of the responsible individual and service users and staff satisfaction surveys. There was no written annual development plan in place or aims and objectives for the coming year. The arrangements for the insurance cover for the home were examined, as were the arrangements, including policy and procedural guidance for the management and handling of service users monies. A number of records, which are required by law to be kept in the home, were examined during the inspection process, these included: Staff records – recruitment, induction and training Statement of Purpose Records of service users monies held by the home Reports made of monthly visits to the home by a representative of the registered provider. Staff duty rotas Records of complaints Accident records Records of fire drills, practises and testing of equipment and procedure Visitors record Arrangements for the promotion of the health and safety of service users and staff in the home were also discussed and records examined, including the core-training provision for staff and the maintenance of equipment, which were satisfactory. The Inspector observed safe working practises during the inspection of the building. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 21 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 2 X X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 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 3 2 3 3 3 3 2 East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES – Not assessed on this occasion. 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 OP2 Regulation 5A Requirement Timescale for action 31/05/05 2 OP7 15(1)(a)& (2) 3 OP3 14(4)(1)& (2) 4 OP7 15(1) & 18(1)(c(i) Individual written terms and conditions must be provided between the home and individual service user in accordance with this regulation. 30.11.04, 31.01.05. NB This standard was not assessed during this inspection. Service users care plans must 31/05/05 identify how their needs will be met and be signed and dated and reviewed at monthly intervals. 30.11.04 & 31.01.05. NB This standard was not assessed during this inspection. Recorded needs assessments 31/05/05 must be provided for each service user which detail all information specified under NMS3.3 – regularly reviewed and revised where necessary. NB This standard was not assessed during this inspection. Staff responsible for written care 30/06/05 plans must receive instruction/training in the following: DS0000035742.V249993.R01.S.doc Version 5.0 East Clune Care Home Page 23 Methods of care planning Records and record keeping (associated with care records). NB This standard was not inspected during this inspection. 5 OP1 4(1)(a)(c) Sch 1 The statement of purpose for the home must be reviewed and a clear criteria defined in relation to short term care admissions (including that relating to assessment, emergency and respite) The registered persons must ensure that the requirements of the Fire Officer detailed in his letter of 23/03/05 are complied with. The registered manager must ensure that there is a recognised process in place for the regular review and monitoring of the efficacy of staffing levels during the late afternoon/evening and night periods. 30/11/05 6 OP19 23(4)(c) 13/10/05 7 OP27 18(1)(a) 13/10/05 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 Refer to Standard OP1 OP33 OP33 Good Practice Recommendations The registered manager should introduce a simple risk assessment tool for the measurement of service users dependency needs. There should be an annual development plan in place for the home, which includes service aims and objectives for that time period. Policies and procedures should be regularly reviewed. East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 East Clune Care Home DS0000035742.V249993.R01.S.doc Version 5.0 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. 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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