Inspection on 07/03/07 for St Clements Nursing Home

This inspection was carried out on 7th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Clements Nursing Home 09/03/09

St Clements Nursing Home 24/01/06

St Clements Nursing Home 26/07/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Clements Nursing Home 170 St Clements Hill Norwich Norfolk NR3 4DG Lead Inspector Maggie Prettyman Unannounced Inspection 7th March 2007 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 St Clements Nursing Home DS0000063411.V332615.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. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Clements Nursing Home Address 170 St Clements Hill Norwich Norfolk NR3 4DG 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) 01603 427487 01603 789407 govinden@providencehealth.co.uk Providence Health Care Limited Mr Govinden Vythelingum Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person under the age of 65 who will be named in the Commissions records. 24th January 2006 Date of last inspection Brief Description of the Service: St Clements was built in 1947 and sits within close proximity to Norwich city centre. An extension was built to increase the accommodation in 1989. The well-tended garden extends out the back of the property in approximately half an acre. The home has accommodation for 24 older people with access to the ground floor and first floor by a passenger lift. The home is suitably adapted to cater for people with varying disabilities in either double or single bedrooms. There is a lounge with an added conservatory, which is used as a dining facility when required. A library, hairdresser and chiropodist visit the home on a regular basis. The current range of weekly fees is £433 - £570. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: This is a good home that demonstrates some excellent standards in some areas of its service. A warm and friendly manager and staff team work in a compassionate and caring way with service users. Needs assessments and health and personal care standards are excellent. Good standards were found in all aspects of daily life and social activities. Service users are happy with the lifestyle and activities in the home. Feedback about the quality, choice and presentation of food was very positive, with an enthusiastic kitchen team providing an excellent service. A service user commented “The food could not be better I get lots of choice, and there is always something I like to eat on the menu”. Minor complaints are listened to and action is taken, and service users are protected from harm by a well-trained staff team and good health and safety practices. A quality assurance system is in place, with many aspects of the home being regularly inspected and audited internally. The home itself is spotlessly clean, pleasant and hygienic, and its facilities and layout are suitable for its purpose. Staff work hard with service users and their families to make individual rooms extremely homely and cosy. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? This home works to continually improve its service. Improvements since the last inspection include; • • • • • • An improved needs assessment process An improved system of medication A dedicated activities worker An in house adult protection trainer An increased staff team A system of staff supervision has been implemented An ongoing programme of maintenance is also in place. One service user said “Having an activities worker has made such a difference to my life, I get to do things that I enjoy and that keep me as active as I can be”. What they could do better: One requirement and three good practice recommendations have been made at the end of this report as follows; Requirement • All staff must be recruited to the standards required by the regulations Recommendations • • • Minor complaints, comments and compliments about the service should be recorded and audited to identify any potential underling patterns and trends. The good practice recommendations of “Safe and Sound” should be adopted by the home for the recruitment of all staff. Falls and accidents should be audited to identify any potential underlying patterns and trends. 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. St Clements Nursing Home DS0000063411.V332615.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 St Clements Nursing Home DS0000063411.V332615.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): Standards 3 and 6 No service user comes to the home without having had a thorough needs assessment. Service users coming for short stays are properly assessed and offered appropriate support. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 9 EVIDENCE: Examination of service users files demonstrated that a comprehensive needs assessment fully meeting the care standards is completed prior to service users coming to the home. A short stay service user’s file demonstrated the same attention to detail and detailed assessments are in place as for long-term service users. People coming for short stays are offered rehabilitation and individual support. St Clements Nursing Home DS0000063411.V332615.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): Standards 7, 8, 9, 10 and 11 Service users Service users Service users Service users is upheld. Service users needs are set out in detailed individual plans of care. health care needs are fully met. are protected by the homes system of medication. feel that they are treated with respect and their right to privacy are given supportive and compassionate end of life care. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of service user files demonstrated excellent standards of care planning drawn from the initial needs assessment and further detailed during the service users initial weeks in the home. All care plans seen demonstrated service user participation and involvement of family where appropriate. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 11 Comprehensive risk and lifestyle assessments are made, and life histories are effectively collated and incorporated into care planning. Evidence from pre inspection feedback from health care professionals as well as discussions with service users and staff and examination of records during the inspection that great importance and care is given to supporting the health care needs of service users. The home is in the process of upgrading its current nutritional assessment to the MUST system. Observation of a drugs round, examination of records and discussion with staff and service users demonstrated that a safe and well-managed system of medication is in place in the home. Evidence of staff training and of audit and checking of medicines was also seen. Feedback from pre inspection questionnaires, observation of interaction between staff and service users as well as discussion with staff and service users demonstrated that service users are treated with the utmost respect and their rights to privacy and dignity are upheld at all times. Post is given unopened to service users, clothes are properly cared for and individually named and privacy in shared rooms is maintained. Evidence that he home uses the Liverpool Care Pathway to support service user end of life care was seen. Records demonstrated that service users and their families are fully consulted about their wishes at this time and that families are offered support and care in a kind and compassionate manner. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Service users find that the lifestyle of the home meets their needs and expectations. Service users retain contact with their families and friends if they wish. Service users exercise choice and control in their lives The food provided by the home is excellent and much enjoyed by service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has improved its social activities since the last inspection by appointing an activities worker. This has been much valued by service users. Life history work helps the home to provide activities suited to the individual needs of its service users. Activities take place both at the home and on trips out. The home has started to produce a newsletter. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 13 Some community groups come to the home, however discussions with staff and service users showed that the emphasis is to go out into the community wherever possible. Service users confirmed that their family and friends are welcomed and supported at all times. Service users choose their individual food daily. The home manager is encouraging service users to come to residents meetings and to complete quality assurance questionnaires. Care plans were seen to be signed by service users or their representatives. Records are kept in service users rooms where they can access them at all times. Service users rooms were individually decorated and contained a wide variety of personal possessions. All service users spoken to were extremely satisfied with the choice, variety and standard of food provided. An experienced and enthusiastic kitchen team provide food according to service user individual needs and wishes. Lists of dietary needs and preferences are maintained. Care is taken in the presentation of liquidised diets. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Service user complaints are listened to. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received by the home since the last inspection. The complaints procedure is placed in each service users room as part of the service users guide. The home does not currently record and audit action taken in respect of minor complaints and comments to help identify any potential underlying patterns and trends. It is recommended that the home records and audits minor complaints as well as comments and compliments. Evidence of POVA training for staff during induction as well as annual update training was seen. A staff nurse is now trained to provide this training in house. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24, and 26 Service users live in a safe well-maintained environment. Service users live in safe comfortable bedrooms with their personal possessions about them. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 16 EVIDENCE: A tour of the premises demonstrated that the home is accessible and well maintained; meeting individual and collective needs in a homely and comfortable way. A competent handy person maintains the home well and safety records are kept. The home is tidy and has attractive and accessible gardens. Work has been undertaken to ensure that environmental and fire regulations are met. During a tour of the premises some service users invited the inspector into their rooms. These were found to be extremely homely and comfortable. Many personal possessions and mementos were seen, with each room being individual to its occupant. Rooms were spotlessly clean and shared rooms had appropriate separation of belongings and personal care items. The home was found to be clean, pleasant and hygienic in all areas, with domestic staff providing a high standard of service. The laundry is quite small, with limited storage, but the manager hopes to expand this in the near future. Sluice areas were found to be clean and tidy. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. The numbers and skill mix of staff meets Service users’ needs. Service users are in safe hands at all times. Service users are not always supported and protected by the home’s recruitment policy and procedures. Staff are trained and competent to do their jobs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of staff rotas, residential forum calculations as well as observation on the day of inspection demonstrated that the home has enough staff to meet the needs of its service users. Extra staff are in place at peak times. Staffing numbers have increased since the last inspection. Records demonstrated that the home continues to encourage its staff to take up and complete NVQ training. Examination of staff files demonstrated some good standards. Identity documentation is now being recorded and validated. However two staff files had references and police checks that had not been properly validated. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 18 It is required that all staff are recruited to the standard required by the regulations, particularly in relation to validation of references. It is recommended that the good practice guidelines in Safe and Sound are adopted by the home. Induction and ongoing training records seen demonstrated that the home operates a good system of in house and external training. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 37 and 38 The home is run by a competent and caring manager. Service users benefit from the management approach of the home. The home is run in the best interests of service users. Service users financial interests are safeguarded. A system of supervision has been introduced. The home keeps excellent records. The health and safety of staff and service users are promoted and protected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 20 The homes manager demonstrated throughout the inspection a professional and caring approach to the home, its service users and staff. His background, experience and training support the excellent standards of management and administration found in the home. Discussions with service users and staff as well as pre inspection information demonstrate that the home is run in an open and positive way. The manager encourages staff and service users to participate in the running of the home. Staff commented on the friendly, professional and supportive management style that they experience. A quality assurance survey has been completed by the home, with outcomes analysed and action taken. The home carries out several monthly audits. Audits of facilities are undertaken by the maintenance person. The home does not manage money on behalf of service users. Small amounts of money are held on behalf of some service users. During the inspection a random selection of accounts were checked and found to be accurate and regularly audited Since the last inspection a system of supervision has been introduced. Supervision agreements have been signed by staff, and supervision sessions are recorded and kept in individual files. Records of mandatory training were seen and found to be up to date. Cleaning materials were safely stored, with staff demonstrating god knowledge and understanding of their responsibilities with regard to safe storage and handling. A selection of safety records were seen and found to be up to date. The home records accidents, but does not currently audit falls and incidents. It is recommended that the home regularly audit falls and accidents to identify any possible patterns and trends. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 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 X X X X 4 X 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 4 4 3 X 3 3 4 3 St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19, Schedule 2 Requirement The home must ensure that all staff are recruited to the standard required by the regulations especially in terms of validation of references and police checks Timescale for action 15/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP16 OP29 OP38 Good Practice Recommendations The home should record and audit minor complaints, comments and compliments to identify any potential underlying patterns and trends. The home should adopt the good practice recommendations identified in “Safe and Sound” in the recruitment of all staff. The home should compile an audit of falls and accidents to identify any potential underlying patterns and trends. St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 St Clements Nursing Home DS0000063411.V332615.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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