This inspection was carried out on 7th October 2008.
CSCI found this care home to be providing an Good service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
Inspecting for better lives Random inspection report
Care homes for older people
Name: Address: Margaret Clitherow House Priory Road two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Michelle Finniear Date: 0 7 1 0 2 0 0 8 Information about the care home
Name of care home: Address: Telephone number: Fax number: Email address: Provider web address: mchaO@tiscali.co.uk Margaret Clitherow House Priory Road 0 Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Margaret Clitherow Housing Association care home 41 Number of places (if applicable): Under 65 Over 65 41 old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 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. Care Homes for Older People Page 2 of 7 What we found:
This random inspection to Margaret Clitherow house took place at the invitation of the homes management committee to review the outcome of a complaint made to CSCI and investigated by the homes management, and to discuss recent correspondence received from the home in relation to a staffing issue. During the course of the visit time was spent with the manager touring the accommodation looking in particular at issues of cleanliness, decoration, and access to fluids for people living at the home. We also looked at concerns that had been expressed about staff response time to call bells. Since the last inspection Margaret Clitherow House has installed a new call bell system, which records exactly how many times a person living at the home has used the call bell, at what time, and how long it took staff to respond. Staff have to physically attend the room to cancel the bell, and a printout is available in the homes office of every call made. This system could clearly demonstrate that staff responded without delay to call bells, and also indicated those people who needed support frequently throughout the day and night. The system also has a capacity to indicate the severity of the call. No evidence could be seen that staff were not responding appropriately to bells. During the tour of the accommodation it was clear that overall the building is maintained to a high standard, however it is an old and listed building that presents many challenges. In particular discussion was held with the manager concerning the replacement of windows, currently on a rolling programme. Many windows have been replaced, with new double glazed wood framed windows, however on the day of the visit which was a very wet and windy day it was clear that people living at the home are still having problems with these. For some rooms whose windows had been replaced there was additional redecoration work required to make good the area surrounding the window and other cracks within the rooms. For other areas of the home it is clear that some windows were in need of cleaning, in particular where there had been a buildup of condensation between the old secondary double glazing and the original window. Some rooms had cobwebs around windows and in one room discussion was held concerning an old area of water intrusion that has left a stained and damaged area. The manager confirmed that the person in this room was unwilling to have this addressed, however the original cause of the damp has been remedied. During the tour observation was made of crockery and peoples access to water within their rooms. People in their rooms had jugs of water available, and some people also had small bottles of water with drinking caps. Two people spoken to said that they had found these to be excellent. Discussion was held on a recent staffing issue which had been handled well by the homes management and reported appropriately to CSCI. What the care home does well:
The home have demonstrated they have responded well to complaints and concerns, in ways that protect the people living at the home. The homes management have demonstrated that they are working hard to try to address the challenges presented by the old building and its listed status. People spoken to on the visit were proud of their rooms and had good relationships with the people providing their care. Care Homes for Older People Page 3 of 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 4 of 7 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set.
No. Standard Regulation Requirement Timescale for action 1 18 1317 Clear records of accidents and bruising to people living at the home must be kept. The manager is to investigate any unexplained bruising. 10/03/2008 Care Homes for Older People Page 5 of 7 Requirements and recommendations from this inspection
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 19 23 The windows require internal 28/03/2009 cleaning This is to ensure that people living at the home live in a clean and comfortable environment. 2 19 23 Repair the damage from water intrusion in one identified room So that people can live in a comfortable and clean environment 26/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No. Refer to Standard Good Practice Recommendations 1 22 The manager is recommended to sample audit the call bell system recordings to provide evidence of the homes responsiveness to call bells as a part of their Quality Assurance system. Care Homes for Older People Page 6 of 7 Reader Information
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