Inspection on 24/02/06 for East Clune Care Home

This inspection was carried out on 24th February 2006.

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

The inspector 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 13/09/05

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 Angela Kennedy Unannounced Inspection 24th February 2006 10:30 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.V285242.R01.S.doc Version 5.1 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.V285242.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service East Clune Care Home Address West Street Clowne Chesterfield Derbyshire S43 4NW 01246 348100 01246 348102 not given 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.V285242.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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.V285242.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over three hours. Twenty-nine residents were residing at the home on the day of inspection. As part of the case tracking process, which determines that resident’s needs are met three residents files were examined, included in this, was information relating tot the admissions process, which was also discussed with the manager and deputy. The medication practices of the home were examined along with the homes menus and meal choices. Several of the residents were spoken with and the manager and deputy were available throughout the inspection. What the service does well: What has improved since the last inspection? Individual written contracts are now in place for all residents at the home (This was a requirement from previous inspections which has now been met). Staff who are responsible for writing care plans now receive in house training in methods of care planning and records and record keeping, this training is ongoing. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 6 The requirement left by the fire officer detailed in his letter of 23/03/05 has now been complied with. Flexi hours are now available and are used when needed to increase the levels of staff available to residents during the late afternoon/evening and night periods. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Residents have a written contract of terms and conditions within the home; however further development is required to ensure that all residents’ needs are met prior to admission EVIDENCE: A contract of terms and conditions of residency was seen within residents files examined, however the financial charges to residents was not included within this contract. The manager stated that this was due to each resident’s contribution to their care being variable, according to assessed needs and financial circumstances. Contracts seen had been signed by the resident or their representative. Discussions took place with the manager and the deputy manager regarding the admissions process for the home. The manager stated that there had been a marked improvement in the recorded needs assessment for the majority of residents prior to admission and evidence was seen in relation to this. The manager stated that an assessment of needs document was not always available prior to admission. Discussions took place at some length, and it was East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 9 agreed that no resident should not be admitted to the home (for respite, emergency, assessment or long term care) prior to an assessment of needs taking place, to ensure the individual residents needs could be met within the home. This requirement should be included within the homes Statement of Purpose. Documents relating to the arrangements and criteria for admissions in regard to emergency, assessment and respite were seen. It was noted that no timescales were given in relation to the length of time these particular beds could be accessed for at any one time. This was discussed in some detail with the manager and deputy manager of the home and agreed that this could have some impact on existing residents accommodated and staffing and workload considerations. Residents spoken with did not express any negative views in regard to shortterm admissions, and expressed positive comments in regard to this, as many of the residents were from the local community and therefore many relationships amongst the residents had been previously established prior to residing at the home. One of the recommendations from the last inspection was that the registered manager should introduce a simple risk assessment tool for the measurement of resident’s dependency needs. Although this standard was not assessed at this inspection, the manager stated that this has not, as yet been achieved. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 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 assessment of residents’ health care needs and an assessment in regard to self administration of medication requires further development to ensure residents needs and safety are fully met. EVIDENCE: Three residents care plans were examined and the majority of residents needs were set out in their plan of care. A requirement left at the last inspection was that staff responsible for written care plans undertake instruction/training in methods of care planning and records and record keeping. The manager confirmed that this training had commenced and was ongoing. Evidence was seen of residents involvement within their care plans in the form of the resident’s signature. It was noted that there was no monthly reviews of the care plans in place; the manager stated that care plans were reviewed on an annual basis including residents that were self-funding and evidence of this was seen. Monthly meetings were held between each resident and their designated key worker and it was said that care plans are reviewed as part of East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 11 these meetings. Evidence to support this would further demonstrate that resident’s needs are met. The lack of risk assessments available within resident’s files was noted and this was discussed with the manager and the deputy. A ‘personal handling’ risk assessment (which related to the moving and handling needs of the resident) was seen in one resident’s file examined; however this had not been completed. No assessments were seen relating to residents who had developed pressure sores or who were at risk of developing pressure sores and the appropriate intervention required. The manager stated that the home prides itself on the fact that no resident had any pressure sores, but did state that one resident was prone to pressure sores, but had not developed any due to the appropriate intervention being given. No nutritional assessments were available within resident’s files however weight charts were available within the residents files seen; these had been completed on a monthly basis. Residents are registered with the local General Practioner (G.P) and G.P visits were documented within the residents files seen. Residents also received visits from the optician, chiropodist and district nurses. Residents were also able to receive treatment from the dentist and audiologist, this however was undertaken outside of the home and staff supported residents in accessing these services as required. The homes practice in administering medication to residents was examined and found to be satisfactory. The manager confirmed that the staff responsible for administering resident’s medication had undertaken the required medication training. One resident living at the home self administered their medication and had signed a declaration stating they were in agreement with this, however there was no risk assessment in place to demonstrate that this resident had the capacity to self administer their medication. This needs to be in place for any resident that wishes to self-administer their medication, in order to ensure the residence safety is maintained. Residents spoken with were very positive regarding the care they received and confirmed that the staff were respectful of their privacy and dignity when providing care and on a day-to –day basis. The manager stated that approximately 75 of the residents received visitors at the home and that residents were able to take visitors to their room or see them in private within one of the sitting rooms if required. The residents spoken with confirmed this. In the resident’s files examined it was noted that the resident’s preferred term of address (name) was not documented, however this information was documented on the residents medicine administration records. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 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): 12,13,14,15 Resident’s social, recreational and religious needs are met within the home and family and friends were able to visit the home as they wished. The meals and meal choices provided at the home received positive comments. EVIDENCE: On the day of the inspection several of the residents were participating in a game of bingo. Residents spoken with were very positive regarding the activities provided by the home. One resident discussed a social outing that was undertaken by 14 of the residents the previous week, where the residents went out for a meal, it was confirmed by this resident that the outing had been very successful and much enjoyed. Several of the residents talked about the religious service that took place within the home on the first Wednesday of each month, from discussions it was apparent that this was enjoyed by many of the resident group. Other residents spoken with talked of the various activities that were provided by the home, which included musical entertainment. Some of the residents spoken with also talked about the hairdresser that visited the home each Sunday. A salon was available within the home for use by the hairdresser. Many of the residents spoken with both male and female East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 13 confirmed their use of the hairdresser and were very positive regarding the standard of treatment provided. The manager confirmed that one of the care staff employed at the home was designated as the homes activity co-ordinator. The activity co-ordinator was not on duty at the time of inspection, and therefore was not available to speak with. It was confirmed by the manager that a book was kept which recorded the activities undertaken; however this was not seen on the day of inspection. Three times a week the home also accommodates a small group of older persons for the purpose of day care, and the manager stated that residents at the home are able to participate within the day care group if they wish to. The manager stated that visiting time within the home was open, although visitors were advised to avoid between 12.15 – 1.00 as lunch was served at this time. Residents confirmed that visitors were made very welcome and private facilities were available for receiving visitors as required. Residents meetings were held on a monthly basis and friends and family of residents were invited to attend. The manager stated that at present no friends or family of residents attended these meetings. Advocacy services were advertised within the home although the manager stated that none of the present residents chose to use this service. Residents spoken with were stated that they did not wish to use the advocacy services at present but confirmed that they were aware that these services were available if required. Residents spoken with confirmed that they were able to choose the time they retired to bed and rose each day and did not feel that any restrictions were imposed on them regarding this. Menus were examined and found to satisfactory. The manager of the home stated that the kitchen staff approached the residents each morning with regard to the meal choices available for each day. Evidence demonstrated that alternatives were made available for residents who required them. Discussions with residents confirmed this. Residents comments regarding the standard of meals provided and the choices available was very complimentary. It was confirmed by the manager that all kitchen staff had undertaken the basic food hygiene course as required. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 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): EVIDENCE: Standards 16-18 were not assessed at this inspection. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 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 The registered person has ensured that full compliance with the Fire Officers recommendations from his inspection in March 2005 has been met. EVIDENCE: This standard was not fully inspected, as this was done on the last inspection – however a requirement from a previous inspection was assessed. This related to a requirement of the Fire Officer detailed in his letter of 23/03/05,with regard to brushes on fire doors, this has now been complied with. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 The minimal staffing arrangements during the evening and at night are reviewed and monitored to ensure resident’s needs are met. EVIDENCE: This standard was not fully inspected, as this was done on the last inspection – however a requirement from the last inspection was assessed. This related to the manager ensuring that a recognised process was in place for the regular review and monitoring of staffing levels during the late afternoon/evening and night periods, which has now been complied with. Flexi hours are now available and are used when needed to increase the levels of staff available to residents during the late afternoon/evening and night periods. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): EVIDENCE: Standards 31-38 were not assessed at this inspection. East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 18 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 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 19 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 OP2 Regulation Schedule 4 (8) Timescale for action A record of the homes charges to 01/05/06 residents, including any extra amounts payable for additional services not covered by those charges, and the amounts paid by or in respect of each resident should be included within the residents contract. New residents are admitted to the home only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective resident and their representative and relevant professionals have been party. Evidence must be in place to demonstrate that residents care plans are reviewed at monthly intervals. The Registered Person shall ensure that the assessment of residents needs are undertaken, kept under review and revised at anytime when it is necessary to do so having regard to any changes in circumstances. 31/03/06 Requirement 2. OP3 Reg 14, Sch 3,1 (a) 3. OP7 Reg15 (2) 01/04/06 4. OP7 Reg14 (2) 30/04/06 East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 20 5. OP8 Schedule 3 (3) (n) 6. OP8 Schedule 3 (3) (m) 7. OP9 Reg 13 (2) Residents are assessed by a person trained to do so to identify residents who have developed or are at risk of developing pressure sores, and the appropriate intervention is recorded in their care plan. Nutritional Screening is undertaken on admission for each resident and subsequently on a periodic basis and records maintained. An assessment of residents capacity to self-administer medications must be in place for all residents wishing to selfadminister their medication. 01/04/06 30/04/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The registered manager should introduce a simple risk assessment tool for the measurement of service users dependency needs. Residents preferred form of address (name) is recorded in residents personal files. 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. 2. 3. OP10 OP33 4 OP33 East Clune Care Home DS0000035742.V285242.R01.S.doc Version 5.1 Page 21 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.V285242.R01.S.doc Version 5.1 Page 22 - 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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