Inspection on 06/05/08 for Abbey Care Home

This inspection was carried out on 6th May 2008.

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

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

Abbey Care Home 11/11/09

Abbey Care Home 18/05/09

Abbey Care Home 08/11/07

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

CARE HOMES FOR OLDER PEOPLE Great Clacton Hall 28 North Road Great Clacton Clacton On Sea Essex CO15 4DA Lead Inspector Ray Finney Unannounced Inspection 6th May 2008 09:30 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 Great Clacton Hall DS0000070394.V365072.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. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Clacton Hall Address 28 North Road Great Clacton Clacton On Sea Essex CO15 4DA 01255 420660 01255 420660 info@careone.co.uk 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) Care One Ltd Mrs Barbara Leggett Care Home 11 Category(ies) of Dementia (11), Mental disorder, excluding registration, with number learning disability or dementia (11), Old age, of places not falling within any other category (11), Physical disability (11) Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home – PC to service users of the following gender: Both Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP Dementia - code DE Mental disorder, excluding learning disability - code MD Physical Disability - code PD Date of last inspection 8th November 2007 Brief Description of the Service: Great Clacton Hall is an established care home that provides residential care for older people. It is registered to care for eleven elderly people over the age of sixty-five, who may or may not have dementia. Great Clacton Hall is a detached period property situated in the centre of Great Clacton, close to the seaside town of Clacton-on-Sea. There are local shops, a supermarket, a G.P. surgery, pubs, churches and public transport nearby. Accommodation is in five single rooms and three double rooms; two of the shared bedrooms (with bath or shower) are on the ground floor and all other bedrooms are on the first floor. The bathroom is on the first floor. Access to the first floor is by means of a staircase. As there is currently no passenger lift, people using the upstairs rooms must be fully mobile. Since August 2007, the home has been run by a new provider, Care One Ltd. The home charges between £394.50 and £550.00 a week for the service they provide. Other services such as hairdressing and chiropody are available at an additional charge. This information was given to us in May 2008. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Great Clacton Hall DS0000070394.V365072.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 1 star. This means the people who use this service experience adequate quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and personnel files. Completed surveys were received from members of staff, people living in the home and their relatives. The proprietor completed an Annual Quality Assurance Assessment with information about the home. This document will be referred to as the AQAA throughout the report. An unannounced visit to the home took place on 6th May 2008 and included a tour of the premises, discussions with people living in the home, a visiting relative, the proprietor, the manager, members of staff and a visiting healthcare professional. Observations of how members of staff interact and communicate with people living there have also been taken into account. At the time of this inspection we at the Commission were gathering information about safeguarding. This was called a ‘thematic probe’ and the information obtained from questions about safeguarding will be fed back nationally and collated into a report at a later date. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and we were given every assistance from the proprietor and the staff team. What the service does well: People living in the home and their relatives are complimentary about the environment and the care provided. One relative said, “The care and support given has been 100 and I can find no fault with Great Clacton Hall at this time” and someone living in the home said “staff are good”. Overall Great Clacton Hall provides a clean, homely environment and is generally well maintained and decorated. The menu provides people with a well-balanced and varied diet. Staff provide home cooked food that is enjoyed by people living in the home. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The 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. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 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 Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Great Clacton Hall receive sufficient information about the home and may be confident their needs will be assessed before admission. EVIDENCE: The proprietor has updated the Statement of Purpose to reflect the changes in the ownership of the home. At the time of the inspection he was in the process of updating the Service User Guide and this was sent to us at the Commission the week following the inspection. The AQAA states that, “We have developed our statement of pupose in a tape version and in One Asian Language version” for people who may have difficulty reading or for those whose first language is not English. Three completed surveys received by us at the Commission all indicated that people had received sufficient information about the home before they moved in. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 9 At the time of the last inspection a recommendation was made that people living in the home should have contracts of residence so that they know what they can expect from their home and what is expected of them. The new proprietor has ensured that all those living in the home have now been given a contract stating the terms and conditions of the home. A sample of three individual files examined all contained a contract, signed by the resident or their representative and a representative of the home (the proprietor and manager). The AQAA states, “Our home has a care plan for each service user which is generated from a comprehensive initial assessment”. A sample of three individual files examined all contained a full assessment of the needs of the person. Staff spoken with were also able to demonstrate a good awareness of people’s needs. At this time the home does not offer intermediate care, therefore National Minimum Standard 6 does not apply. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their personal and healthcare needs will be met in Great Clacton Hall and that they will be treated with respect. EVIDENCE: The AQAA states that people have a care plan that is generated from the initial assessment and that the care plan is the basis for meeting people’s needs and promoting their independence and that the plans are drawn up with the involvement of the person living in the home. The sample of three care plans examined had all been revised and updated since the last inspection. There are a range of care plans identifying the person’s needs, the objective in trying to meet that need and a plan of care. Care plans are signed by the person or their representative. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 11 The AQAA also states that care plans contain individual risk assessments, including a falls risk assessment, which are reviewed six monthly or when a risk is identified. Records examined confirm that there are new risk assessments in place identifying any risk to the individual and actions taken to reduce the risk. Staff spoken with demonstrate a good awareness of people’s needs. Two people spoken with said staff care for them the way they like. One relative spoken with on the day of the inspection said they were confident that their relative’s needs were being “well met” in Great Clacton Hall. Care plans contain a ‘Latter Stages of Life’ plan that documents people’s wishes and requests around their end of life needs. Three people responded in surveys that staff are “always” available when they need them. A relative said in a completed survey, “the manager and staff have looked after my relative for a number of years. The care and support given has been 100 and I can find no fault with Great Clacton Hall at this time”. The AQAA states that all those living in the home have access to relevant healthcare services, including monthly visits from a chiropodist and annual visits from a dentist and an optician. Evidence was examined of input from doctors and district nursing services. The sample of care plans examined covered a range of healthcare needs. There are weight charts in place. We discussed people’s needs around diabetes with the manager. The district nurse comes in daily to administer insulin and has trained staff in how to carry out blood tests to monitor blood glucose levels. Completed blood glucose charts examined. The manager and staff spoken with were able to demonstrate of good awareness of people’s healthcare needs. A relative spoken with said their relative’s health “is looked after by staff” and they have “no concerns”. In three surveys completed by people living in the home two people indicated that they “always” receive the medical support they need and one person said, “I have pretty good health for my age”. Great Clacton Hall operates a Monitored Dose System for administering prescribed medicines. There have been improvements in procedures around medication since the last inspection. All out of date medication is now returned to the pharmacy. Storage appropriate in a securely locked cupboard, which was seen to be kept tidy. There are currently no controlled drugs in use but proprietor was able to demonstrate an awareness of the requirements around appropriate storage and recording of controlled drugs should anyone be prescribed this type of medication. Medicine administration record (MAR) sheets examined were completed appropriately. A discussion with proprietor and manager also demonstrated an awareness of appropriate storage of medication that may need to be kept in controlled temperatures such as eye drops. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 12 Overall, there are now good practices being followed that will ensure people are supported with prescribed medications safely. As at the last inspection people continue to speak positively about the way they are treated. One person said that personal care is provided in a dignified way and a relative spoken with also said they had no worries around their relative being treated with respect. The AQAA states that, “all our service users privacy and dignity are respected when our carers provide personal care by closing the room doors and respecting their wishes when communicating with them”. Observations on the day of the inspection confirm that staff are courteous and treat people with respect. Staff were observed knocking on people’s doors before entering individual’s rooms. Great Clacton Hall DS0000070394.V365072.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Great Clacton Hall have opportunities to maintain a lifestyle that meets their needs and wishes. EVIDENCE: Information provided in the AQAA states that there are activities for people to take part in if they wish. Care plans examined contain information about the activities that people like to take part in, such as music, armchair activities and tactile or musical toys to help stimulate the senses. Members of staff spoken with know people’s likes and dislikes well. Although there were no organised activities taking place on the day of this inspection, people were relaxed and staff were engaging people in conversation. One person with a visual impairment was listening to music and their relative who was visiting said that they have ‘talking books’ which the library brings. Another two people were interacting with bricks and toys and were smiling and obviously enjoying the activity. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 14 The staff team encourage people to keep active but their choices are respected if they choose not to join in with activities. Two people spoken with choose not to join in activities and prefer to remain in their room reading and watching television. In a completed survey, when asked about activities, one person said, “Does not interest me”. The proprietor said they are planning to have a local priest come in to the home to give Holy Communion. The minutes of a recent residents’ meeting confirmed that activities were discussed. One person said when the weather gets better they “would like to go round the shops” and another said they are “quite happy” watching the ‘soaps’ on television and listening to stories on tape. The AQAA states that relatives and friends can visit people whenever they want, although they ask people to make prior arrangements if they are going to visit after nine o’clock in the evening. A visiting relative spoken with said they visit every few days and are always made welcome. They said that their relative is “happy in the home”. As reported at the last inspection people are able to get up and go to bed when they choose. The AQAA states that people “are encouraged to exercise their autonomy and choice”. People spoken with said they were satisfied they had a degree of control within the home. One person said if they didn’t like something they “would tell the staff”. The AQAA states, “meal planning is done with the involvement of the service users”. The minutes of a residents’ meeting were examined and confirmed that people’s likes and wishes around food were discussed. Overall people are now happy with the changes to the menus. Dinner on the day of the inspection was minced beef, potatoes and vegetables with bread and butter pudding for dessert. People appeared to enjoy the meal. Staff spoken with were able to explain about individual likes and dislikes around food. Food stocks examined confirm that there was a good range of fresh, frozen, tinned and dried foods available. A visiting relative also said they had “no complaints” about the food. Great Clacton Hall DS0000070394.V365072.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Great Clacton Hall are safeguarded by staff who follow the home’s procedures around complaints and protection. EVIDENCE: The complaints record examined showed improvements since the last inspection in the recording of concerns and complaints. The provider has updated the complaints policy and sent a copy to us at the Commission. Three surveys received from people living in the home all confirmed that they know who to speak to if they are not happy and they know how to make a complaint. Similarly, two completed surveys from relatives confirm that they are aware of what to do if they wish to make a complaint. A visiting relative spoken with said that they knew how to make a complaint. The home has a policy on Protection of Vulnerable Adults (POVA). Records show that staff have received training around safeguarding issues delivered by the local Primary Care Trust. Staff spoken with able to demonstrate a good awareness of their responsibilities around keeping people safe and reporting any suspicions of abuse. The proprietor said that staff have received POVA booklets to back up the training and records examined confirm that staff have signed to say they have received this information. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 16 The recruitment process has been improved and enhanced Criminal Record Bureau Checks (CRB) are now obtained before employing staff. A sample of records examined confirmed that CRB certificates are in place. Personnel records also confirm that staff have received training around safeguarding matters. Staff spoken with are able to demonstrate an awareness of their responsibilities around safeguarding vulnerable people. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall people benefit from a homely environment, however they cannot be assured that they can access all parts of the home. EVIDENCE: A tour of the premises confirmed that, as at the previous inspection, the communal areas and bedrooms are well-maintained. Furnishings are domestic and comfortable and people living in Great Clacton Hall benefit from the homely surroundings. All bedrooms are individual and show evidence of personal possessions such as ornaments and photographs. One person spoken with said they like spending time in their room. The AQAA states, “We have a routine maintenance programme to repair and maintain the building”. There have been improvements in the maintenance of the property since the last inspection. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 18 These include repairs to the fire door closure and a bath hoist which is now securely installed, which were issues previously identified in an Environmental Services visit. Access to the first floor of the home is by stairs and there is no passenger lift installed. The proprietor explained that they had planned to improve this by providing a stair lift. A stair lift was ordered but was not installed because the curve of the staircase meant people would not have been able to get past the stair lift safely. The proprietor has plans for building work that will include a passenger lift so that people who are not mobile can access the first floor of the home. Until these plans are completed people with restricted mobility are prevented from accessing all areas of the home, including the upstairs bathroom. The standard of cleanliness around the home is good with no evidence of odours throughout. The equipment in the laundry is appropriate for the size of the home and the laundry was clean. The AQAA states that they “have a policy and procedure in place to control the spread of infection” and soiled laundry is “washed above 65 degrees for 10 minutes”. Since the last inspection, issues around poor practices in transporting soiled laundry through the home have been addressed and staff follow procedures that will ensure people are kept safe from risk of cross infection. Three completed surveys from people living in the home all said that the home is “always” fresh and clean. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, people living in Great Clacton Hall benefit from a competent staff team, although more evidence could be provided to demonstrate that there are sufficient staff to meet people’s needs at all times. The recruitment procedure provides the safeguards that ensure appropriate staff are employed. EVIDENCE: The AQAA states that they, “have experienced carers on duty all the time” with two carers during the day in order to meet the assessed needs of people living there and one awake staff on duty at night as people, “all go to bed at night time”. Staff rotas confirm that there are two members of staff on each shift during the day and one person at night. The proprietor said that he calculated the staffing levels according to the assessed needs of the people living in the home and has carried out a risk assessment around having one ‘awake’ staff on at night. Three surveys completed by people in the home all said that staff are “always” available when they need them, although one person also said, “at night time when only one staff is on I can’t use the commode”. On the day of the inspection the home, which is registered for up to eleven people, was not fully occupied and the needs of the six people currently living there were seen to be met by the number of staff on duty. However, at least one person required the assistance of two people to mobilise and therefore, would not be able to mobilise during the night if there was only one member of Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 20 staff on duty. The home must be able to demonstrate that staffing levels meet individual needs at all times. The AQAA states that they meet the National Minimum Standard of having 50 of care staff with National Vocational Qualification (NVQ) at level 2 or above. The proprietor said that 95 of care staff have either completed or are in the process of doing NVQ at level 2 or above. The sample of personnel records examined contains evidence of NVQ awards. The proprietor confirmed that he has tightened up on the recruitment process. The AQAA states that they “take two references out of which, one from the previous employer. Before employment we check them with the CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) in order to protect our service users. We explore any gaps in the employment with the staff before employment”. Improvements have been made to the personnel records since the last inspection. The proprietor has updated the files and the sample examined all contained the documentation required, including appropriate references, CRB and POVA First (the register of people barred from working with vulnerable people) checks. There have also been improvements in staff training since the last inspection. The proprietor demonstrated that he has put a programme in place to update staff training and this has commenced. The AQAA states the home has, “a rolling training and development programme to update the staff knowledge, skills and experience”. Records examined show evidence of training around medication, diabetes and understanding dementia and also evidence that there is an induction process in place for new staff. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall Great Clacton Hall is adequately managed, although the manager needs to acquire qualifications that demonstrate she has developed the skills and competencies needed in the day-to-day running of the home to show that the home is run in the best interests of the people who live there. EVIDENCE: The manager has worked at the home for over 17 years and has a National Vocational Qualification (NVQ) Level 2 in care and the new proprietor has been in discussions with her around appropriate qualifications for a registered manager. As reported after the last inspection in November 2007, a registered manager would be expected to undertake an NVQ Level 4 in care and the Registered Managers Award (RMA). Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 22 There have been a number of improvements to some of the procedures since the new providers took over, particularly around record keeping, recruitment and staff training. Discussions with the proprietor, manager and members of staff show that the new proprietor visits at least once a week, sometimes more frequently, and takes a hands on role in the managing of the home by implementing new procedures, updating policies and dealing with staff disciplinary issues. However, as recommended at the previous inspection, the registered manager should achieve appropriate qualifications in care and management to develop skills to continue to improve the day-to-day management of the home. The AQAA states, “We have developed a quality monitoring system for our service users, families and other stake holders. These are done on annual basis in order to monitor our perfomance”. The proprietor was able to explain some of the things that they have done in response to issues that have been raised by people in the home or their relatives. A relative spoken with was confident that their views are listened to. There are now monthly staff meetings and regular staff supervisions where people are able to make their views known. Overall the proprietor is able to demonstrate that the service responds to people’s views and wishes. As at the last inspection, there is a process in place for recording transactions relating to people’s monies. Receipts are kept of purchases made for individuals and records/cash balances examined were in order. As previously reported, a member of staff has been acting as Department of Work and Pensions appointee for one person for over five years. This involves collecting the person’s weekly benefits, paying their residential fees and recording personal expenditure. These transactions are recorded in detail and there is an appropriate audit trail. Since the last inspection improvements have been made to the supervision process. The AQAA states that staff, “receive six supervision a year and an appraisal to find out the gaps they have and act to fulfill these gaps in order to promote good practice”. Personnel records examined contain evidence that supervisions are now being carried out regularly. Records examined show that the policy around the Control of Substances Hazardous to Health (COSHH) was updated in August 2007 and staff have had in-house COSHH training. There is a procedure on the use of Personal Protective Equipment such as gloves and aprons, which were seen to be used by staff carrying out care tasks. There were issues around infection control at the last inspection when staff were seen to handle soiled laundry without the use of gloves or aprons. Records examined confirm that this was addressed with staff and practices around infection control have improved. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 23 Since the last inspection risk assessments have been carried out and window restrictors have been installed on upstairs windows, which has improved safety for people living in the home. There have also been improvements in maintenance checks and recording. Portable Appliance Testing (PAT checks) were carried out on 9th April 2008. Fire risk assessments are in place, staff have had fire training and smoke alarms had a maintenance check in April 2008. Maintenance certificates were examined for checks on the gas installation (21st August 2007) and electricity (20th January 2008). Records show that weekly checks are carried out on emergency lighting and fire alarms. Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 24 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 X X 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Great Clacton Hall DS0000070394.V365072.R01.S.doc Version 5.2 Page 25 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 OP21 Regulation 23(2)(a) Requirement People must have access to all areas of the home, designed for their use. This includes ensuring people with restricted mobility have means to access the facilities on the first floor, including the bathroom. This is a repeat requirement from the inspection carried out on 8/11/07. Timescale of 31/01/08 to meet the requirement was not met. Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP31 OP27 Good Practice Recommendations The manager should achieve the National Vocational Qualification in care and management, Level 4, to assist her in running the home. The manager should ensure that there are sufficient staff on duty at all times to meet the assessed needs of people living in the home. DS0000070394.V365072.R01.S.doc Version 5.2 Page 26 Great Clacton Hall Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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