Inspection on 16/08/07 for Margaret Clitherow House

This inspection was carried out on 16th August 2007.

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

Margaret Clitherow House 07/10/08

Margaret Clitherow House 29/11/06

Margaret Clitherow House 09/03/06

Margaret Clitherow House 19/07/05

Margaret Clitherow House 17/11/04

Margaret Clitherow House 29/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Margaret Clitherow House Priory Road Torquay Devon TQ1 4NY Lead Inspector Michelle Finniear Unannounced Inspection 16th August 2007 08:05 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 Margaret Clitherow House DS0000018395.V341726.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. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Margaret Clitherow House Address Priory Road Torquay Devon TQ1 4NY 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) 01803 326056 01803 315066 margaretclitherow@btconnect.com Margaret Clitherow Housing Association Mrs Margaret Parsons Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29/11/06 Brief Description of the Service: The Margaret Clitherow House provides residential care for up to 41 older people. There are 38 bedrooms, of which three could be double if required. All but one room has en suite facilities, and that one has an adjacent wc. Most of the Home is accessible via the shaft lifts, with a short flight of steps to some rooms. There is a dining room large enough to seat all the residents while providing quiet corners. There are two shared sitting rooms, a gazebo and a conservatory. There is a kitchenette where residents may make hot drinks or snacks, if assessment shows this to be safe. The Home has extensive gardens, which are accessible to residents. There is suitable garden furniture and shade provided. Vegetables are grown for the kitchen. The Home is adjoining the Catholic Church, and is close to the St. Marychurch precinct with all its amenities and services. Transport is provided for medical appointments and social activities. There is a Residents Social Fund, which pays for entertainments. The Manager will supply a copy of the latest CSCI report on request. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at Margaret Clitherow house since their last inspection visit in November 2006. To help CSCI make decisions about the home the manager gave us information in writing about how the home is run; documents submitted since the last inspection were examined along with the records of what was found on that visit; a site visit of 9 1/2 hours was carried out with no prior notice being given to the home as to the specific date and timing of the visit; discussions were held with the manager and staff on duty; various records were sampled, such as medication records and accident logs; questionnaires were sent to staff who work at the home and the people who live there; a tour was made of the home and garden; and time was spent with the people living there. In addition a sample group of residents were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management from the early days of their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that residents views of the home forms the basis of this report. Nine people living at the home or their relatives and eleven staff completed questionnaires about the home, and returned them to CSCI. What the service does well: Margaret Clitherow House has an air of formality and respect, which is appreciated by residents living at the home. Residents are encouraged to retain their independence and to exercise choice and control over their daily lives. Excellent information has been produced for prospective residents, including a video portraying life at the home. The home always sends a member of staff, often one of the managers, to medical appointments and hospital admissions, even during the night in the event of an emergency, if family are unable to attend. This was seen during the site visit when a very frail person had a senior staff member accompany them on an urgent hospital admission following a fall. Social activities are provided regularly in the home. Many people at the home spoke of the importance of maintaining their faith and living in a community Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 6 where this was accessible to them. The home is linked internally to the adjoining Roman Catholic Church. The meals are very good, with choices available and care taken in the presentation. A varied vegetarian option is available each day, and the home can cater for diabetic diets. There are utility rooms on the first and second floors, where residents can make their own hot drinks and snacks. The complaints procedure is on display in the home, and residents have found that when they have brought something to the attention of the Manager, it is dealt with promptly, without any difficulty. The house is well-maintained, imposing and full of period features. The majority of rooms have a level access to one of the two shaft lifts that service floor above the ground level. Comments from People who answered questionnaires included: “When I visit I notice a very friendly atmosphere about the home. The staff welcome visitors. Everywhere is very clean and tidy. I feel they do a good job, far better than some I have visited” “Facilities and care are excellent. Grounds are beautiful” “The care is excellent. The carers are kind and considerate to my mother. She is under no pressure from anyone and can lead her life as she sees fit in residential care”. What has improved since the last inspection? A number of areas of the building have been refurbished, including a conservatory being rebuilt and the paths to the garden have been laid with Tarmac, so enabling people who are wheelchair users or need walking aids to have better access to these areas. Changes have been made to employment procedures to honour changes in age discrimination and retirement legislation. This means that staff can work beyond the age of 65 if they wish. There is a new locked cupboard for secure storage of controlled medication. Staff have attended courses in funeral care arrangements and care of the deceased, so they have a better knowledge of caring for people who have died. Improved efficiencies have been made in the homes laundry services. This has meant that peoples laundry is returned quicker and fewer things get lost. Staffing levels have increased. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 7 What they could do better: Care plans should be drawn up in consultation with the resident, to ensure their agreement. Personal profiles or social histories should be developed, in order to enhance knowledge and communication. This has been a requirement at two previous inspections and has not yet been met fully. The home should have an effective quality monitoring system in place, and an annual development plan, based on a systematic cycle of planning, action and review, and reflecting aims and outcomes for residents, so that all can be aware of and involved in the development of the service. This has been a requirement at a previous inspection and has not yet fully been met. A full recruitment procedure must be followed for all staff, including the obtaining of references and criminal records bureau checks. This helps to protect people at the home from being cared for by people who may be unsuitable to work with vulnerable people. Prescription dressings should not be in a general first aid kit, to ensure they are not used for people for whom they are not prescribed. Expired dressings must be returned to the pharmacist or destroyed. More person centred information should be made available in care plans. Management plans should be provided for areas of challenging behaviour. This helps to protect people living and working at the home and ensure that staff are working consistently. A full system of individual supervision should be implemented. This helps to make sure staff are working consistently and to their full potential. All taps delivering water to people living at the home should deliver the water at temperatures below 43 degrees centigrade to ensure people are not accidentally scalded by hot water. Please contact the provider for advice of actions taken in response to this Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 8 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. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 9 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 Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6. Quality in this outcome area is good. Good information is available to help people judge if Margaret Clitherow House is the right home for them. People are well assessed before a decision is made about whether the home is suitable to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Margaret Clitherow House has a statement of purpose and service user guide available for people living at the home, as well as people considering moving in. This documentation contains information about the home, such as these services and facilities available, and any restrictions that may be placed upon people living at the home. The service user guide is available in large print, and the home also has a video available for people so that they can see what the home is like. This information can help people make a decision about whether the home is the right place for them. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 11 The service user guide also contains a copy of the homes contract. Copies of completed contracts were seen in peoples files, and these contain additional information on the fees to be paid and what people can expect in return. This helps to ensure everybody understands and their rights and responsibilities. Prior to a decision being made about whether the home is suitable, a full assessment is completed on the person seeking admission. The home has an application form, which is completed and then usual practice would be to visit the person wishing to move to the home, and hold discussions with the person and their carers or relatives to be sure that the home can meet their needs. This means that it is less likely that people have to move on because the home was unaware of particular requirements relating to their care. People are also encouraged to visit the home before making a decision about admission. Discussions were held with people living at the home, and several explained that they knew of the home previously, or had chosen to come and live at Margaret Clitherow House because of the close links and proximity to the Catholic Church to which the home is physically linked. Discussion was held with the manager on the process that had been followed before a recent admission. This had included the manager visiting this person in hospital and completing assessments before a decision on admission was made. The home does not cater for intermediate care. This means that they do not provide specialist rehabilitation programmes for people with a view to returning them to their own homes. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 12 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, 10. Quality in this outcome area is good. Care planning and recording systems require some attention to ensure they properly reflect the needs of people living at the home. Medication systems are satisfactory, and peoples health care needs are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the site visit eight peoples care plans were inspected in detail, discussions were held with the management and staff, information from questionnaires regarding health care provision was seen, a discussion was held with a district nurse who was visiting the home on the site visit, and time was spent with a number of people living at the home discussing the way their care was delivered. Since the last inspection in 2006 the home has obtained a new care planning system. Care Plans are important as they identify areas where people need support, and show how that support is to be given. They help to ensure that Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 13 peoples needs are met in a consistent fashion and in accordance with their wishes. Eight peoples care plans were seen in detail. The plans seen did not contain sufficient information on the persons needs in some cases, specifically in relation to the direct delivery of care. For example one care plan indicated that full assistance was required with regards to this persons management of hygiene. However no further information was available to explain what this meant in practice or how exactly the person wished their care to be delivered. Another indicated that a person required dressings and that they were attending to them themselves but there was no indication as to why these dressings were needed. Discussions were held with a member of staff regarding the actual care delivered to two people. The care staff was clear about the persons preferred routines and the care needed. However much of this was not recorded in the plan. Some care plans were being signed by the people themselves, however many others were not, and there was no indication that the person had been involved in their drawing up. Discussions with one of these people later indicated that they had been consulted on the contents of the plan and had contributed to a part of the plan relating to their social and personal history. Peoples involvement is important as it ensures that as far as possible the care is delivered in the way that they wish. The home has equipment and systems available to support peoples healthcare needs. The manager confirmed that appropriate mattresses for pressure relief are available, as well as bath and mobile hoists to support peoples moving and handling needs when their mobility is impaired. People spoken to confirmed that their healthcare needs were being met. Some people spoken to felt that they were mainly self caring, but were glad to know that staff were there if they weren’t able to manage on their own in future. During the visit a person living at the home had fallen and needed emergency treatment. This was managed smoothly with concern for the persons wishes and dignity as well as their health needs. First aid was appropriately administered until paramedical support arrived. This demonstrated that the staff were knowledgeable and able to manage in a crises. Medication systems were also seen on the site visit. Medication received into the home is recorded, and staff sign records when they give someone living at the home their prescribed dose. This should allow for a full audit trail, however on some occasions staff had not signed correctly for medication given. The home uses a blister pack system, where medication is sent by the pharmacist in a series of pre-prepared blister packs, which makes it easy for staff to identify with the medication has been given and reduces risks of error. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 14 Staff have received training in administration of medication, which is always given out by senior trained staff. Some people living at the home are able to manage some aspects of their own medication, for example inhalers and angina sprays. This helps them feel secure that their medication is at hand and ensures it is available in an emergency. The home handles some controlled medication, which is subject to special security arrangements due to its strength and effects. Controlled medication records are completed by two members of staff, and correctly reflected the balance held. Some prescription dressings were being held within the homes first aid kit both on the ground and the first floor. This is not appropriate as they may be used in an emergency, not for the person for whom they had been prescribed. In addition one had expired in 2004. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 15 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, 15. Quality in this outcome area is good. People at Margaret Clitherow House have opportunities to follow their chosen lifestyles. The home is respectful, and formal. People receive a well balanced and attractive diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit time was spent with the majority of people living at the home, discussing their lives and their experience of living in Margaret Clitherow House. Information was also taken from questionnaires, and from information supplied by the management of the home prior to the inspection site visit. Margaret Clitherow house provides a home for people whose needs vary considerably from those who are mostly self caring, through to others who have quite high care needs. Many of the people spoken to cited as the main reason for moving to Margaret Clitherow house, its links to the local Catholic Church. A corridor from the home opens directly into the church, allowing for an easy access. The home is Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 16 however non-denominational, with residents and staff of any faith or none being able to live and work there. The home provides some organised group activities, which range from poetry readings, book readings, exercises, music and bingo. The home has extensive and productive gardens including kitchen gardens, the paths of which had been recently laid to Tarmac, which has made them accessible to people with mobility problems. People living at the home have also had opportunities to have an area of the garden to themselves for cultivation as they wish. The homes gardener keeps people living at the home regularly updated with developments. There are also attractive seating areas for people to sit outside weather permitting. A person who lives at the home writes a regular newsletter giving information about local happenings and there are opportunities for people to mix at coffee and mealtimes daily. Breakfast is served at 9 a.m. and the majority of people take this in the dining room, along with all other meals. One person said they got up at 6:30 a.m. and could have a cup of tea as they wanted at that time but chose to wait until the breakfast at 9:30. There are small kitchenettes on each floor where people living at the home and prepare themselves a drink or light snack if they wish. One person at the home has a budgerigar, which is able to free fly in their room. They also take care of a caged bird in a communal part of the home. The home does not accept cats or dogs or other small pets. One person living at the home is a smoker and a small area to the rear of the home which is enclosed has been designated for their use. Smoking is not allowed in other areas, but would be outside. The home has a formal atmosphere and people living there are addressed and referred to by their full names in accordance with their wishes. Discussion was held with the manager on increasing the amount of recording on person centred care and lifestyle choices in peoples files. A relative commented that “Friends and family are always made welcome”. One person living at the home has become involved in helping some staff members improve their English language skills. This has proved of great benefit to both parties, and the person who lived at the home said how nice it was to feel useful and that they could make a contribution. The home has a menu planner which showed a good variety and choice of meals served. There is a daily vegetarian option in addition. On the day of the site visit the main meal was Roast beef, Yorkshire pudding, swede, cabbage and roast and boiled potatoes. The vegetarian option was a vegetarian vol-au vent. Dessert was a meringue nest with fresh strawberries and cream. The evening meal was sausage and chips or sandwiches, soup or a salad. People spoken to confirmed that the meals were of a good quality and were enjoyed, Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 17 including fresh vegetables and fruit from the homes garden. Special diets can be catered for, currently diabetics. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 18 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, 18. Quality in this outcome area is good. Complaints systems are in place and work successfully. The adult protection systems are satisfactory but more training is needed to ensure all staff have the skills and information to protect people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure available, which is displayed on a notice board in the dining room and is given to each person at the home. People spoken to on the site visit or who completed questionnaires indicated that they were clear about who they would raise any concerns with. No significant complaints have been received by CSCI or by the home since the last inspection. The home has a vulnerable adults policy and procedure available. Some staff have attended external training in Adult protection and other training is planned for the near future. Staff spoken to or observed during the site visit were respectful of peoples rights and choices. Where people present challenging behaviour appropriate management plans and records will provide protection for both staff and themselves. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. Margaret Clitherow House provides a comfortable place to live and work in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Margaret Clitherow House is an imposing and impressive building, originally built as a convent and later converted for residential care. The home now has 38 bedrooms, three of which are large enough to be used as double rooms if required. All rooms but one have en-suite facilities, which range from a full bath and toilet to just a toilet and wash hand basin. The corridors are wide, and there are two shaft lifts to enable access to all floors. A few rooms still have to be accessed by a small flight of steps, so would not be suitable for people with mobility problems. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 20 The home offers a variety of communal space and period features. There are two lounges and two conservatory areas and a large dining room. Corridors and communal areas show evidence of the homes past with religious statuary pictures and photographs. Peoples individual rooms varied considerably with some having high ceilings and sea views to others which provided near separate day and night space and views over the gardens. Rooms were in the main bright and well furnished. The home is attempting to progress with a programme of the replacement and double glazing of windows, as it is acknowledged some of the older period arched windows are draughty. One person living at the home stated that their windows had been replaced, but they still had a draught when the wind was in the wrong direction. Peoples bedrooms were personalised, and showed evidence of the personality and style of the person living in them. One room had an area of damp infiltration which was being dealt with at the time of the visit. The home has extensive garden areas, and is situated adjacent to the St Marychurch shopping precinct and is joined to the nave of the Roman Catholic Church through an internal corridor. The home has extensive service areas, including an office, clinical room, servery and storage areas, a large laundry and kitchen. The small smoking area is provided to the rear of the home, accessed through a store room. A hairdressing/chiropody room is situated on the first floor, and was being well used on the day of the inspection. On each floor there is a small kitchen where people living at the home can prepare for themselves a snack or hot drink if they wish. Some people living at the home also had small fridges in their bedrooms. All areas seen on the site visit were clean and free from unpleasant odour. Discussion was held with the manager on movement of soiled or contaminated laundry throughout the home and this appeared satisfactory. A disinfecting system has been installed to assure the safe washing of all laundry and bed linen. Stocks of disposable gloves and aprons are kept in the bedrooms of residents who have on-going personal care needs. There is a suitable place for sterilising commode pots. Information completed by the manager prior to the inspection confirmed that the development priorities include an upgrading of the homes electrical system. Quotes have been obtained. In the last 12 months garden paths have been laid with tarmac, repairs to windows are ongoing, a full fire precautions risk assessment has been completed and work required by the fire officer has been undertaken, some stainless steel work surfaces have been replaced in the servery and a conservatory has been rebuilt. This demonstrates that the Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 21 homes management committee are working hard to ensure people live in an attractive and homely environment. Relatives who completed questionnaires said that “Margaret Clitherow House is a lovely property, the staff keep it very homely” Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 22 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, 30. Quality in this outcome area is good. Some areas were adequate. There is a stable and effective staff group who provide care to people living at the home. Attention is required to some staff recruitment procedures which help to protect people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence was seen from staff files, discussions with staff on the site visit, questionnaire responses, discussions with people living at the home and information received prior to the inspection from the homes manager to make a judgment about the staffing arrangements at the home. The home has had relatively little staff turnover in the last year which means that staff have had the opportunity to get to know people living at the home well and can provide continuity with their care. People who completed questionnaires said that “The staff at Margaret Clitherow House are all very good” and “The care is excellent. The carers are kind and considerate to my mother. “ Staffing levels seen on the visit were satisfactory to look after the needs of the people living at the home, including when there was an emergency admission to hospital. A senior member of staff was able to escort the person to hospital Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 23 to ensure their needs were catered for and that they were supported by someone familiar to them. There are regular monthly staff meetings, the minutes of which were seen. Training and development plans were available for the staff, showing developmental training and core training updates needed. Core training would include areas such as first aid, food hygiene, infection control and moving and handling practices. Recent training has been given to staff in fire prevention, moving and handling and first aid. Some staff have received training from an external provider in the Protection of vulnerable adults and others are due to do this in the near future. Staff are also undertaking National Vocational Qualifications at levels 2 and 3. National vocational qualifications are a nationally recognised award reflecting the competency of staff in the workplace. Four staff files were selected for inspection on the site visit, reflecting the staff on duty and those most recently appointed. Files seen generally contained the required recruitment information. One file for a person from abroad contained only a criminal records bureau check from their country of origin and not from this country, even though they had worked at another care home prior to starting work at Margaret Clitherow House. Two of the files did not contain copies of two references. Criminal records bureau checks and references help in ensuring that people at the home are being cared for by people who are suitable to be working with vulnerable adults. The home has a volunteer worker who helps staff in the homes dining area. Staff spoken to on the visit and who completed questionnaires said “The home is run very efficiently with a very good staff team who strive to meet the needs of all the clients. It has a very friendly atmosphere, very clean and well run.” And “The home has an excellent reputation for the 1st class treatment given to our residents and the lovely clean and friendly environment enjoyed by all of us.” Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 24 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, 38. Quality in this outcome area is good. The home is being well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion was held with the manager about the management systems at the home, some documents were sampled along with some observation of systems in use and discussions were held with staff on some aspects of health and safety for example moving and handling and infection control. The manager is experienced and has worked at the home for many years. She has completed her NVQ4 in management and has achieved the Registered managers award, which is a qualification specific to managing a care home. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 25 People spoken to on the visit said she has high standards but is approachable and good at her job. Mrs Parsons is supported by the homes management committee which is drawn from ladies of the Catholic Womens league throughout the West country. Staff supervision systems were not being provided at the standard set rate of six times per year. Staff supervision is a system combining performance management and staff development, and involves each member of staff taking time with their manager on a regular basis looking at any issues to do with their work or performance, and any training or support they need. It aims to ensure staff are working at their potential, and giving consistent care to service users. Service contracts were said to be in place for gas safety certificates, records of the servicing of the shaft lifts and records of tests on electrical appliances, which are carried out annually. The home has some risk assessments available in relation to the building and it’s maintenance, and the home has a maintenance person who is able to tackle jobs as they arise. The home has cupboards for the safe storage of cleaning chemicals, and has some data sheets available. Data sheets record what to do for each product in the event of accidental misuse. The home has a health and safety policy. Fire precautions at the home are regularly tested and the system was last serviced on 26th June 2007, which was documented in the log book and servicing records. Regular servicing helps to ensure the system would work appropriately in an emergency. All water outlets are now stated to be regulated. This means that service users are protected from any risks of scalding as the water cannot be delivered to the taps at more than 43 degrees centigrade. However one person was unhappy with the taps on their bath and the water temperature that came out. The water temperature from this persons wash hand basin was very hot and the manager agreed to ensure this was re-tested and re-calibrated if necessary. Staff training files contained information on staff training in some health and safety issues such as moving and handling tasks, fire protection and infection control. The system for managing peoples finances was on previous inspections where it was found to be satisfactory. The home has a financial administrator who deals with all support in this area. The home has purchased a quality audit system and has started it’s implementation, along with questionnaires for people living at the home, their relatives and other stakeholders. These systems will gain as much information Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 26 as possible bout peoples experience of the home and help them identify what is working well and what can be improved. Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 27 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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2) Requirement A plan of care should be drawn up with the involvement of each resident, agreed and signed by them (or their representative), setting out in detail action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care are met. Previous timescales 30/04/06 and 31/01/07 not met. The registered Person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home, and shall supply to the Commission a report… and make a copy of the report available to service users. Previous timescale 30/6/07 not met. A full recruitment procedure must be followed for all staff, including the obtaining of references and criminal records bureau checks., Timescale for action 30/10/07 2. OP33 24 30/10/07 3. OP29 19 30/09/07 Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 29 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 OP9 Good Practice Recommendations Prescription dressings should not be in a general first aid kit, to ensure they are not used for people for whom they are not prescribed. Expired dressings must be returned to the pharmacist or destroyed. More person centred information should be made available in care plans. Management plans should be provided for areas of challenging behaviour to ensure staff are working consistently. A full system of individual supervision should be implemented All taps delivering water to people living at the home should deliver the water at temperatures below 43 degrees centigrade to ensure people are not accidentally injured. 2. OP14 3. 4. OP36 OP38 Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Margaret Clitherow House DS0000018395.V341726.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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