Care Home: Clare House

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What the care home does well Prospective residents are fully assessed prior to admission to ascertain that the home is able to meet their needs. They are also encouraged to visit the home so they can make an informed choice. Assessments for health care needs and risk were in place and associated documentation had been completed where a need had been identified. The home has good input from healthcare professionals. The home has an excellent and varied activities provision, and activities are seen as an integral part of each residents day. The home has an open visiting policy and visitors are made very welcome. Information regarding advocacy services is available, thus ensuring each resident`s right to independent representation is respected. The food provision is of a high standard, offering wide variety and choice, with a strong emphasis on meeting each residents dietary needs and preferences. There are clear systems in place for the management of complaints and safeguarding adults, and these are followed. The home is being maintained, and there are major refurbishment plans for 2009, showing that BUPA recognise the need for the home to be updated. Bath & shower facilities had been reviewed in the last year. Infection control procedures are in place and are followed, and the home is clean and fresh throughout. Residents personal laundry is well cared for. The home is appropriately staffed to meet the needs of the residents and the Manager has kept this under constant review. The home has comprehensive induction and training programmes in place and there is evidence of ongoing training for all staff. The Manager has the skills and experience to manage the home, and does so effectively. Residents, staff and visitors said that the management team is approachable and deal promptly with any issues raised. There is a good system in place of auditing and review for quality assurance, and action is taken to address any shortfalls identified. Personal monies held on behalf ofresidents are being well managed and securely stored. Health and safety is being well managed at the home. The results of the surveys were very positive and comments to include the following were received: `This is the very best home that I have come in contact with and I have no complaints whatsoever.` `carers are second to none and the nurses are excellent.` What has improved since the last inspection? Clear administration instructions for each medication are now recorded on the medication administration record (MAR), and all administration and reason for any omissions are clearly recorded. Prescribed medications had all been recorded on the MAR. A system for flushing water outlets in line with legionella prevention guidance had been put in place. The laundry room floor had been reviewed and a fully sealed repair carried out. Risk assessments for kitchen equipment and safe working practices are now in place. What the care home could do better: Updates of the care plans had not always been completed promptly following a change in their condition. Documentation for wound dressing changes was incomplete and therefore was not an accurate reflection of the number of dressing changes that had been carried out. Although overall medications are being well managed, shortfalls were identified regarding the suitability of the lancing devices that were in use for blood glucose testing, which could place residents at risk. There was also some confusion noted in respect of the method of disposal used for a medication, and all staff must understand and follow the current procedures for the correct disposal of medication. Photographs and health check questionnaires could not be found in 2 of the staff employment files viewed. All required documentation must be available for inspection. CARE HOMES FOR OLDER PEOPLE Clare House Harefield Road Uxbridge Middlesex UB8 1PJ Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 11:10 26 & 27th August 2008 th 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 Clare House DS0000010928.V370488.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. Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clare House Address Harefield Road Uxbridge Middlesex UB8 1PJ 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) 01895 272 766 01895 272 896 bartonto@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd Mrs Anna Francis Dempsey Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 43 30th August 2006 Date of last inspection Brief Description of the Service: Clare House is a 43-bedded Care Home providing nursing care for older people. The purpose built building is situated on a busy thoroughfare leading into Uxbridge town centre. Transport links are by bus. There are 35 single rooms, thirty-four with en suite washbasins and toilets. One single room has a washbasin. There are four double rooms, all with en suite facilities, which are used for single occupancy. The ground and first floors are connected by stairways and a passenger lift. All parts of the home are wheelchair accessible. Wheelchair access is also provided for some of the bedrooms that open onto the patio area. The home provides a large parking area at the front of the building and a well maintained garden to the rear. Clare House DS0000010928.V370488.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 16 hours was spent on the inspection process. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 17 staff and 5 visitors were spoken with as part of the inspection process. The CSCI Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, staff and healthcare professionals have also been used to inform this report. What the service does well: Prospective residents are fully assessed prior to admission to ascertain that the home is able to meet their needs. They are also encouraged to visit the home so they can make an informed choice. Assessments for health care needs and risk were in place and associated documentation had been completed where a need had been identified. The home has good input from healthcare professionals. The home has an excellent and varied activities provision, and activities are seen as an integral part of each residents day. The home has an open visiting policy and visitors are made very welcome. Information regarding advocacy services is available, thus ensuring each resident’s right to independent representation is respected. The food provision is of a high standard, offering wide variety and choice, with a strong emphasis on meeting each residents dietary needs and preferences. There are clear systems in place for the management of complaints and safeguarding adults, and these are followed. The home is being maintained, and there are major refurbishment plans for 2009, showing that BUPA recognise the need for the home to be updated. Bath & shower facilities had been reviewed in the last year. Infection control procedures are in place and are followed, and the home is clean and fresh throughout. Residents personal laundry is well cared for. The home is appropriately staffed to meet the needs of the residents and the Manager has kept this under constant review. The home has comprehensive induction and training programmes in place and there is evidence of ongoing training for all staff. The Manager has the skills and experience to manage the home, and does so effectively. Residents, staff and visitors said that the management team is approachable and deal promptly with any issues raised. There is a good system in place of auditing and review for quality assurance, and action is taken to address any shortfalls identified. Personal monies held on behalf of Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 6 residents are being well managed and securely stored. Health and safety is being well managed at the home. The results of the surveys were very positive and comments to include the following were received: ‘This is the very best home that I have come in contact with and I have no complaints whatsoever.’ ‘carers are second to none and the nurses are excellent.’ 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. Clare House DS0000010928.V370488.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 Clare House DS0000010928.V370488.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): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, to ascertain that the home is able to meet their needs. EVIDENCE: The home has a pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and were comprehensive and clear. Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 9 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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation was generally complete, however shortfalls in updates could lead to residents needs not being fully identified and met. The home has good input from healthcare professionals, thus ensuring the residents healthcare needs are being met. Overall medications are being well managed at the home, thus safeguarding residents. Shortfalls should be easy to address. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home is progressing the processes for discussing and recording the wishes of residents and their families in respect of end of life care, to ensure that their wishes can be respected and met. EVIDENCE: 5 service user plans were viewed as part of the inspection process. The preadmission document is used to identify each residents needs and care plans had been formulated to address them. There was evidence of monthly reviews of the care plans and associated documentation. Care plans had not always been updated following a hospital admission and the importance of this was discussed with the registered nurses. There appeared to be some gaps in the Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 10 recording of when wounds dressings had been carried out, however there was evidence that the wounds were improving and the registered nurses explained that it was likely that the dressing had been done but this had not always been recorded. The importance of recording was discussed with the registered nurses. These points were also discussed with the Manager. Risk assessments for falls were in place and had been reviewed regularly. Assessments for moving & handling were in place and the specific equipment to be used for each individual had been identified. Assessments were also available for nutrition, continence and pressure sore risk. Care plans for wound care were in place and identified the dressing regime to be followed for each wound. Pressure relieving equipment was seen in use and had been identified in the care plans. There was evidence of input from healthcare professionals to include GPs, optician, chiropodist, speech and language therapist, tissue viability nurse and physiotherapist. One healthcare professional was spoken with and said that the staff are helpful and do follow any specific instructions for each resident. The AQAA records that registered nurses are ‘link nurses’ for various groups, for example, tissue viability and Parkinson’s Disease. These nurses attend meetings and bring the current good practice information back to share with their colleagues to improve resident care. Residents spoken with said that they do receive input from healthcare professionals. Medication management was viewed. Lists of registered nurse signatures and initials were available. An information sheet was available for each resident to include their name, photograph and any allergy information. A homely remedy sheet had been completed for each resident. For residents who wish to selfmedicate an assessment is carried out and a self-medicating agreement completed and signed. For residents on warfarin therapy a copy of the most recent blood test results to include the current dosage is kept with the medication administration record (MAR) charts. Receipts had been recorded for all medications received into the home. Administration records were up to date and all administration had been signed for or the correct coding used if a medication had been omitted. Stock checks were accurate for medications received in boxes. Liquid medications, creams and eye drops had been dated when opened. The lancing devices being used for blood glucose monitoring were not of a type approved for professional use. This was discussed with the Manager and a CSCI Pharmacist Inspector also spoke with the homes supplying pharmacist about this issue. The Manager has since confirmed that correct lancing devices for professional use are now in use in the home. The temperature records for the medication fridge were within the safe range of 28° centigrade. On occasion the clinical room temperature was recorded as being above 25° centigrade. The Manager said that she had purchased 2 air conditioning units and that on hot days air conditioning would in future be used in the clinical room to keep the temperature within safe range for storing medications. The home uses the weekly NOMAD system for medications. The medication information available on the back of each box viewed was complete and accurately reflected the contents. Copies of all prescriptions are retained Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 11 by the home. Controlled drugs had been correctly recorded and stock checks carried out evidenced accurate recording and stock control. The approved method for medication disposal is in use in the home and with one exception medications had been correctly disposed of. The Manager said that she would follow up on the one medication for which there had been some confusion regarding the disposal method used. For one medication that had a variable dose action needed to be taken to ensure that if the medication is to be provided in the NOMAD box, then the correct dose for each day is provided so that staff do not have to dispose of the tablets not required on a specific day. Clear administration instructions were recorded on the MAR charts. Medications were being securely stored in the home. Overall medications are being well managed in the home and the shortfalls identified should be easy to address. Staff were seen caring for residents in a gentle and professional manner, using each residents preferred term of address and respecting their privacy and dignity. Staff were seen communicating with residents in a respectful manner and there was a good rapport noted between residents and staff. Bedrooms had been personalised and there was a homely feel throughout. Residents can have their own telephones, either mobile or landline. Residents spoken with said that they were being well cared for, and they looked well groomed and were dressed to reflect individuality. Residents also confirmed that their chosen times for getting up and going to bed are respected. In the service user plans viewed there was information regarding the wishes of residents and their families in respect of a deterioration in health and ‘end of life’ care. The information varied in depth, and the registered nurses explained that they have input from the Macmillan nurses regarding progressing this sensitive area of care and ensuring the wishes of all the residents and their families are ascertained. The Manager said that this is a topic that she now approaches during the assessment process and is a very important part of each residents care. Clare House DS0000010928.V370488.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): 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The activities provision is very varied, and each residents’ right to choose to join in is respected, thus meeting their individual needs and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is of a high standard, offering a wide variety and choice, with resident’s choices being clearly ascertained and respected. EVIDENCE: The home has a full time activities co-ordinator. The weekly activities programme is on display throughout the home and a copy is also given to each resident. There is evidence of regular outings and in house entertainments taking place in addition to the activities provided. For each resident a ‘map of life’ is completed and this records life history information and also each persons individual hobbies and interests. From this information activities for groups of residents can be planned, for example, the Gardening Club for those who enjoy gardening. We observed group activities taking place and residents were having a very enjoyable and sociable time. One to one activities are also Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 13 carried out with those residents who are not able to partake in the group activities. There is a film afternoon at the weekends and also residents take the initiative to arrange their own activities on occasion. 5 staff have undertaken MIDAS training to drive the community bus and this has resulted in an increase in the quality outings during the summer months. Every 3 months a draw is held, and 2 residents win a special outing, for example, afternoon tea at The Ritz. Some residents have joined the National Trust and speakers attend the home to give talks. The home also has input from representatives from various religious denominations, who visit the home. Residents spoken with enjoy the activities provided at the home and it was clear that the activities are an integral part of the daily routine. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and refreshments are offered. Visitors commented about the homely atmosphere throughout. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was displayed on notice boards throughout the home. The home has information from Age Concern, a support group for residents and relatives in Hillingdon and advocacy services to provide financial advice. We viewed the kitchen. This was clean and tidy and all the records were up to date. Residents are offered a choice of meals and documentation to evidence this was available. The menus are on display and there are 2 main meal options, however a wide variety of alternatives are available and it was clear that the catering staff have a very positive attitude towards ensuring each resident’s preferences are catered for. Residents spoken with said that they enjoy the food provision at the home. Soft diets and Pureed meals are well presented. We sampled the lunchtime meal on the first day of inspection and the food was well presented and tasty. Visitors are also able to partake in meals should they wish to, for an agreed fee. Staff were available to assist residents with their meals as needed, and did so in a gentle and discreet manner. We observed the lunchtime and evening meals and residents were enjoying the food and there was a very sociable atmosphere. The overall impression of the meal provision is that the residents’ individual preferences are top priority and everything is done to ensure these are met. Clare House DS0000010928.V370488.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): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There are robust procedures in place for safeguarding adults, to protect residents from abuse. EVIDENCE: The home has a clear complaints procedure on display in the reception area. Residents spoken said that they felt able to raise any concerns with the Manager. There had been 6 complaints in the last 12 months and these had been investigated and responded to in accordance with the complaints procedure. The home has policies and procedures for safeguarding adults and also has contact with the Hillingdon Safeguarding Adults Team. Staff spoken with confirmed that they had received training in this area and were very clear to report any concerns, plus they understood the Whistle Blowing procedures. Clare House DS0000010928.V370488.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): 19, 21 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being maintained with further improvements planned, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: We carried out a tour of the home. Overall the home is being maintained and BUPA has major refurbishment plans for the home in 2009, to include a review of the lighting. Written records of the areas redecorated are kept and redecoration work is carried out when rooms are vacant. There was evidence of this seen in two rooms that had been made ready for admissions in the near future. The fire risk assessment had last been reviewed in December 2007 and in addition individual fire risk assessments have been carried out for each residents room and action taken to minimise any risks identified. The garden is Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 16 well maintained and residents are encouraged to have their own garden areas, with raised flowerbeds also available for residents to plant in. The home has had a review of the assisted bath and shower facilities. A new bath has been installed and a new shower facility also. 2 bathrooms that were not used have been converted into storage rooms and this has helped to address the shortage of storage space in the home. Residents spoken with were happy that they receive the help they require for their daily care. We viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. Good practice notices and laundering guidelines were on display. There are 2 washing and 2 drying machines of industrial standard plus ironing equipment available. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean and fresh throughout. Clare House DS0000010928.V370488.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): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place to protect residents, however all documents required must be available to evidence these are being followed. The home has a comprehensive induction and training programme to provide staff with the skills and knowledge to care effectively for the residents. EVIDENCE: At the time of inspection the home had 33 residents. The home was being appropriately staffed to provide good care to the residents and to meet the needs of the residents and the home in general. The staff rosters viewed evidenced that the staffing levels are maintained in line with resident dependencies. The Manager has clearly reviewed the staffing in the home and where gaps had been identified, people have been recruited to these posts and as a result the home no longer uses agency staff and is developing a stable staff team. The home has over 50 of care staff trained to NVQ in care level 2 or above. Training information and documentation evidenced that staff receive training in topics relevant to the diagnoses and needs of the residents. There is a comprehensive training programme and the home has a newly appointed head of training to ensure there is ongoing input into the training of staff. Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 18 Three sets of staff employment records were viewed. With the exception of 2 photographs and 2 health check questionnaires, these contained all the information required under Schedule 2 of the Care Homes Regulations 2001. It was explained that there were documents awaiting filing at the time of inspection. The importance of ensuring all documentation is available for inspection was discussed. The Manager has since confirmed that the missing documentation is now in place. The home has an induction programme based on Skills for Care Common Induction Standards. Staff spoken with said that they had received induction training to include health & safety topics. The full induction programme takes place over 12 weeks and then the member of staff and their mentor sign to evidence that all sections of the induction booklet have been completed. Residents spoken with were satisfied that staff caring for them have the skills to do so effectively. Clare House DS0000010928.V370488.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): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed effectively in an open and transparent manner, prioritising the care of the residents. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are in place and are being well managed. EVIDENCE: The Manager is a first level registered nurse with relevant management experience in older peoples care settings. She is currently undertaking the Registered Managers Award and has attended several BUPA training sessions in management topics, plus has undertaken health & safety training. The home also has a deputy Manager with several years relevant experience, plus the Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 20 staff, residents and visitors spoken with said that the Manager and her team are very approachable and that any issues raised are addressed. The home has a quality assurance system with regular audits of areas to include care planning, medications, and the kitchen. A comprehensive home audit is carried out annually and this is due for completion in the autumn. Regulation 26 unannounced visits to the home take place monthly, and a copy of the report is forwarded to us. The Registered Manager has weekly Heads of Department meetings. Separate meetings for the registered nurses and for the care staff are carried out every 4-6 weeks. Minutes are taken and samples of these were viewed and provided a clear picture of the discussions at the meetings. The Manager said that she had held an Open Evening for relatives and residents, and is planning meetings that will be held at differing times and on differing days so that there is an opportunity for everyone who wishes to attend. The home now has a Residents Committee that consists of 6 residents who can ascertain the views of other residents and speak on their behalf as part of the quality assurance for the home. The home also has a quarterly newsletter, which this is informative, and BUPA sends out a company newsletter also. The home has an interest earning bank account dedicated to residents’ personal monies. The homes administrator maintains very comprehensive, itemised records for each residents individual income and expenditure, thus providing a clear audit trail for all service users monies. A monthly statement is sent to the resident or the representative responsible for their finances to evidence all expenditure. Relatively small amounts of money are held on behalf each service user, and additional funds are requested as and when required. Records of all monies received on behalf of service users are maintained. The system of managing service users monies is very robust and thorough and the administrator ensures records are well maintained. The servicing and maintenance records were viewed at random and those viewed were up to date. A system has been put in place to ensure that the water outlets in vacant bedrooms are flushed in line with legionella safety procedures. The need to ensure that when staff are on leave a second person is identified to keep jobs such as this up to date was discussed with the Manager and she said that this would be implemented. Staff training records evidenced that staff had undertaken health & safety training to include moving & handling, infection control, first aid, fire safety and food hygiene. The due dates for individual staff training updates in mandatory topics are flagged up on the computerised training records system. Risk assessments for equipment and safe working practices were in place and were up to date. Clare House DS0000010928.V370488.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X 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 3 X 3 X 4 X X 3 Clare House DS0000010928.V370488.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 OP7 Regulation 15(2)(b) Requirement Service user plan documentation must be reviewed following any changes in a residents condition, so that they provide an accurate picture of their condition. Whenever a wound dressing is renewed this must be recorded to ensure the records are accurate and up to date. The MHRA advice with regard to blood glucose testing must be followed in order to safeguard the residents. All staff must clearly understand the procedures for the disposal of medications, to ensure the correct method is used. The home must ensure that all documentation listed in schedule 2 of the Care Homes Regulations is in place for all employees, to safeguard residents. Timescale for action 01/10/08 2. OP7 17(1)(a) 01/10/08 3. OP9 13(2) 01/09/08 4. OP9 13(2) 01/09/08 5. OP29 19 01/09/08 Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 23 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 OP9 OP38 Good Practice Recommendations That the process for supplying variable dosage medication be reviewed to minimise any associated risks. That a system be put in place so that when a member of staff responsible for health & safety checks is on leave, this role is fulfilled by a second, appropriately trained member of staff. Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Clare House DS0000010928.V370488.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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