Care Home: Clumber Court Care Centre (Care Home)

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What the care home does well People are supported to live in a safe and comfortable environment. The home undertakes suitable pre-admission assessments and provides prospective residents/representatives with information about the service. Relatives we spoke with said that they received the information they needed about the service to help them to make decisions about placements. Two relatives we spoke with had been recommended to consider Clumber Court byother members of the community who had experience of the home, and they had chosen this home in preference to others that they had visited. Relatives report that they feel that staff provide a good standard of care to the people living at the home. Comments from relatives that we spoke with included: `The staff are great` and `Staff do everything they can`. Staff are suitably trained, enthusiastic and committed, and appear to develop good relationships with the people who live there. During the inspection visit we observed that staff respected peoples` rights to privacy and dignity. Relatives we spoke with felt able to raise any concerns with staff, and consider that the management and staff genuinely listen to them and take any necessary steps to resolve any issues of concern. People are provided with a nutritionally balanced diet, with a good range of choice on the menus. A person dining during our visit said they were having `a lovely meal`. A range of activities is provided and efforts are made to adapt the programme flexibly to meet the individual social and leisure needs of the people living at the home. A registered manager leads the home and utilises quality monitoring and quality assurance measures to promote the safety and wellbeing of the people living at the home. What has improved since the last inspection? The service has worked hard to address the requirement made at the last inspection regarding aspects of the care planning, and there are no outstanding requirements from that inspection. Care planning processes have been improved to ensure that pre-admission assessments are fully considered in the development of individual care plans. The care plans are person-centred and there is the involvement of individuals and representatives in agreeing the plans of care. There are on-going improvements to the environment, with themed decoration of corridors and communal areas. Many areas of the home have been redecorated and refurbished since the last inspection and further improvements have been authorised by the company. For example, new floor coverings are on order for corridor areas. What the care home could do better: It has not been necessary to make any requirements at this inspection. A recommendation has been made to further develop the care planning processes to specifically record the capacity of people to make their own decisions. The manager informed us that the company has a working party in place with the aim of ensuring that care planning systems are suitable for staff to record and acknowledge their responsibilities in line with the Mental Capacity Act 2005. A recommendation has been made to provide more detailed temperature monitoring of one of the medication refrigerators. CARE HOMES FOR OLDER PEOPLE Clumber Court Care Centre (Care Home) Bolham Lane Retford Nottinghamshire DN22 6SU Lead Inspector Andrew Bailey Unannounced Inspection 12th January 2009 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 Clumber Court Care Centre (Care Home) DS0000024636.V373650.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. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clumber Court Care Centre (Care Home) Address Bolham Lane Retford Nottinghamshire DN22 6SU 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) 01777 700823 01777 705143 clumbercourt@schealthcare.co.uk Ashbourne Homes Ltd Nicola Aisthorpe Care Home 64 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (64), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (64) Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2007 Brief Description of the Service: Clumber Court Care Home was established in 1993 and is now owned by Southern Cross. The care home is situated in the market town of Retford and enjoys a pleasant, picturesque and quiet location alongside the river Idle. Clumber Court is built on two levels and caters for the care of older people and offers specialist residential and nursing care for up to 64 older people with dementia type illness. There are sufficient communal areas throughout the building and there is a pleasant secure garden for service users to enjoy. Accommodation is provided in single rooms and service users are encouraged to bring in personal possessions in order to personalise their rooms. The current range of weekly fees is from £344 to £577 and for private placements £385 to £430. Rates and further information about the home is available to prospective service users and/or their representatives on initial enquiry. Clumber Court Care Centre (Care Home) DS0000024636.V373650.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 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for the people who use the service. The process of inspection considers the home’s capacity to meet regulations and minimum standards of practice, and looks at any aspects of service provision that may need further development. The inspection was unannounced and took place over a period of eight hours. For the purposes of inspection we have taken into account information that we hold about this service. This includes our previous key inspection report of 24th May 2007 and information provided in the Annual Quality Assurance Assessment (AQAA) questionnaire completed by the home. At the time of this inspection there were fifty-eight people living at the home. We used case tracking as part of our methodology. This means that we looked more closely at the care and services that four of those people were receiving. We did this by looking at written care plans and associated health and personal care records. Due to the nature of the illnesses of the people living at the home we spoke with as many visiting relatives as possible to seek their views on the service. We also observed staff interaction with some of the people who use the service. We spoke with management and staff about the arrangements for matters such as recruitment, induction, training and the general running of the home. We also had the opportunity to speak briefly about the service with a General Practitioner who was visiting residents at the time of the inspection. What the service does well: People are supported to live in a safe and comfortable environment. The home undertakes suitable pre-admission assessments and provides prospective residents/representatives with information about the service. Relatives we spoke with said that they received the information they needed about the service to help them to make decisions about placements. Two relatives we spoke with had been recommended to consider Clumber Court by Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 6 other members of the community who had experience of the home, and they had chosen this home in preference to others that they had visited. Relatives report that they feel that staff provide a good standard of care to the people living at the home. Comments from relatives that we spoke with included: ‘The staff are great’ and ‘Staff do everything they can’. Staff are suitably trained, enthusiastic and committed, and appear to develop good relationships with the people who live there. During the inspection visit we observed that staff respected peoples’ rights to privacy and dignity. Relatives we spoke with felt able to raise any concerns with staff, and consider that the management and staff genuinely listen to them and take any necessary steps to resolve any issues of concern. People are provided with a nutritionally balanced diet, with a good range of choice on the menus. A person dining during our visit said they were having ‘a lovely meal’. A range of activities is provided and efforts are made to adapt the programme flexibly to meet the individual social and leisure needs of the people living at the home. A registered manager leads the home and utilises quality monitoring and quality assurance measures to promote the safety and wellbeing of the people living at the home. What has improved since the last inspection? The service has worked hard to address the requirement made at the last inspection regarding aspects of the care planning, and there are no outstanding requirements from that inspection. Care planning processes have been improved to ensure that pre-admission assessments are fully considered in the development of individual care plans. The care plans are person-centred and there is the involvement of individuals and representatives in agreeing the plans of care. There are on-going improvements to the environment, with themed decoration of corridors and communal areas. Many areas of the home have been redecorated and refurbished since the last inspection and further improvements have been authorised by the company. For example, new floor coverings are on order for corridor areas. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 7 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. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 8 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 Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 9 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): NMS 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service, or their representatives, receive information to help them decide whether the service can meet their needs, and they have the opportunity to visit the home before choosing to live there. EVIDENCE: In the Annual Quality Assurance Assessment (AQAA) document that we received before this visit the service told us that they offer a homely and welcoming atmosphere where people are given choice and opportunity to be as independent as possible. We case tracked four of the people living at the home. This included looking at their care records and where possible speaking with their relatives during the visit. We were able to speak with three relatives about the admission process. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 10 Relatives felt that they had received suitable written and verbal information about the care home before deciding if it was the right care home for their family member. In one instance there had been an emergency placement, which then subsequently became permanent. In two other cases a relative had looked at alternative placements and felt that Clumber Court offered the best setting for their mother/father. Two relatives had received recommendations about Clumber Court from people in the community who had experience of the care home. We noted that there was written information about the service on display in the entrance area of the home and in the bedrooms that we looked at during the inspection visit. We spoke with the manager about the admission process. It was confirmed that trial visits are encouraged before a decision is made about a possible placement. The manager explained that unless an emergency placement is necessary, the home’s staff undertake a full pre-admission assessment prior to admission to the home, with full consideration taken of additional assessments by external professionals. Reviews take place within six weeks of a placement to evaluate whether the needs of a person are being met by the home and whether the placement is a suitable one. We saw record of a documented initial placement review. There had been the input of the person living at the home, the social worker, staff from the care home and a relative. The care records of the people that we case tracked contained assessments from which more detailed care plans had been developed. Where appropriate, Social Services and NHS assessments had been received and considered prior to admission of the person to the home. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 11 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): NMS 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care needs of people living at the home are met and staff respect their rights to privacy and dignity. EVIDENCE: In the Annual Quality Assurance Assessment (AQAA) the service said that staff maintain the privacy and dignity for all the people living at the home. They told us that they encourage people to have more involvement in decision making through the use of advocacy, where this is appropriate. They said that all of the people living at the home have life histories compiled, identifying likes and dislikes, and that these are completed soon after admission to the home, with the help of relatives. The AQAA told us about the developments to care planning, with the plans forming the focus of care, and a more personcentred approach. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 12 We spoke with the relatives of people living at the home and they confirmed that staff respect the privacy and dignity needs of the people living there. A relative confirmed that staff knock on the bedroom door before they enter the room. We spoke with the manager and she told us that one of the members of staff has the role of ‘Dignity Champion’. This senior carer promotes dignity through measures such as teaching other staff, and providing resource materials and prompt sheets. The manager told us that the ‘Dignity Champion’ and other staff have looked at particular dignity topics, such as bathing and the provision/availability of toiletries in bathrooms. Relatives we spoke with felt involved in the care planning processes. Relatives also said that there was appropriate communication with them about any health changes relevant to their relative. The written evidence that we examined in the records of the people that we case tracked supported the views of those we had spoken with. We found that relatives had been invited to sign the records to indicate consultation with them and their agreement with the content of the plans. Relatives had been invited to attend reviews, and a communication log demonstrated the ongoing communication links with relatives. We examined the care plan records of the four people that we case tracked. The individual care plans had been formulated from pre-admission assessments, information from other professional agencies, and from risk assessments undertaken by staff at the home. The records we looked at had been subject to regular review to ensure that the documented care needs had not changed and were still relevant. The records we examined were detailed, included relevant risk assessments and were of a good standard, with evidence of regular review and update. We looked for evidence within care plans that consideration had been given to the capacity of people to make decisions for themselves. The manager told us that several of the staff had attended training to learn more about the Mental Capacity Act 2005, and the implications it has for people living in a care home. The care plans are person-centred and generally acknowledge the capacity, preferences and abilities of an individual. However, the manager told us that the company (Southern Cross) has recognised that there is a further need to ensure that people’s capacity to take decisions forms an integral part of the normal assessment and care planning arrangements. The company has set up a working party to look at ways of ensuring that there is full compliance with their assessment and recording responsibilities under the Act. The home caters for persons with dementia and dementia type illness. We looked at whether the staff had the relevant experience and training for this client group. Relatives told us that they felt that staff were skilled at caring for Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 13 their family members. We also spoke to a General Practitioner (GP) who was visiting the home to examine residents. The GP praised the staff for their knowledge of the people living at the home, their approach to caring for them and the communication with the medical services about peoples’ conditions. The manager told us about the dementia type training that staff had received. This included training on dementia awareness, challenging behaviour, and Yesterday, Today, Tomorrow (YTT) training. The latter is to become mandatory for all staff, with about twenty percent having currently undertaken this. Further training, called Non-Aggressive Physical Psychological Intervention (NAPPI) has also taken place and is being considered for further inclusion in the training programme. We looked at the medication systems and there were no matters of serious concern. There had been a recent external audit of the medication systems carried out by a community pharmacist in September 2008, with no outstanding matters for the home to address. We did note that whilst the nursing unit monitors the medication refrigerator temperatures with a maximum/minimum reading thermometer, the residential unit use a single reading temperature thermometer. The maximum/minimum method ensures monitoring of temperatures is within given parameters. The manager agreed to obtain a maximum/minimum thermometer for monitoring the temperature of the refrigerator on the residential unit. Staff had received medication training, and this included training last year about the use of syringe drivers (a method of administering medication by injection). A member of staff reported that the General Practitioners review the prescribed medication for people using the service at least every three to six months. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 14 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): NMS 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity programme is designed to meet the individual needs and abilities of the people living at the home. People receive a good standard of catering to meet their nutritional needs and choices. EVIDENCE: The service told us in their annual self-assessment that they ensure that all people living at the home have care plans that incorporate their personal choices and that there are dedicated activity areas. They told us that they had increased the sensory areas in the home and continually look at links with the community to improve the range of activities available. They told us that life histories are compiled for each person to inform the social and leisure needs provision available to each individual. The service explained that they provide nutritionally balanced diets and that people choose from a varied menu. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 15 During the tour of the building we were shown the themed areas. A local school had undertaken a project to design and develop a theme for one of the first-floor corridors (a seaside theme). Another corridor has pictures of the Retford of past years, and a communal area has been designated a quiet area with a ‘Rose Cottage’ theme. One of the ground floor corridors has the theme of ‘Avenue Garden’, with a floral emphasis. We case tracked four of the people living at the home. Each person had person-centred care plans, which included activities and life histories. The documentation had a record of the activities that the person had participated in. The manager told us that the philosophy is to not have strict routines, and to flexibly meet the needs of the people living at the home, whilst recognising that for some people a routine may be needed as part of their daily living strategies. The manager told that that they consult with families to ascertain known likes, dislikes and preferences of people at the home. She emphasised that people are always ‘asked’ and never ‘told’. There is an activities coordinator employed at the home. She usually works Mon – Fri in the daytime, but this is flexible to allow for specific social activities ‘out of hours’. A weekly programme of activities/events is displayed on the notice board. On the morning of the day of the inspection, the hairdresser was visiting the home. Once a week some of the people go to the Reflections Café, run by the Alzheimer’s Society. Transport is provided for this outside visit. An external ‘Motivation Company’ visits monthly and provides a programme including motivational chair based exercises. The home has links with local schools and ‘shows’ have been held at the home. Also, some people have visited the schools to enjoy concerts, with car or taxi transportation provided. There are links with the New Life Christian Centre, with monthly hymns and songs at the home. Holy Communion takes place at the care home and one of the people living at the home attends bible reading, accompanied by the activities coordinator. There are periodic outside trips, for example, last year a trip to ‘The Deep’’ at Hull (an aquarium). Over Christmas there were parties, carol concerts, bell ringing and a pantomime. A relative we spoke with said that the food was good and varied and that their relative enjoyed their meals. We observed the midday mealtime on the day of the visit. People choose from the menu items (four-weekly rotating menu) and we witnessed staff ascertaining the meal preferences of people during the mealtime. Staff were on hand to support people who needed assistance with feeding. The mealtime was unhurried and people seemed to enjoy the food served. A person dining during the visit told us it was ‘a lovely meal’. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 16 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): NMS 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 responds appropriately to concerns and complaints and aims to protect people from harm. EVIDENCE: The AQAA self-assessment that we received prior to the inspection told us that any complaints are recorded, investigated, and dealt with in line with Southern Cross policy. They told us that complaints are tracked to establish any trends. The service told us that feedback has been positive from people who have utilised the complaints procedure and that follow up is always provided to anyone raising concerns. During discussion with staff at this visit, they confirmed that they had received training in the protection of vulnerable adults (safeguarding adults). This training alerts staff to recognise abuse and respond to any allegations of abuse. Training records that we examined supported that staff had received training on safeguarding adults, whistle blowing and customer care. When we spoke to the relatives of people using the service they told us that they feel that management is approachable, and that staff will listen to them and take any issues of concern seriously. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 17 We looked at the complaints records and it was confirmed that complaints had been responded to in an appropriate and timely manner. The most recent complaint, in September 2008, had been about some missing property item. The complaint had been suitably handled and a written response provided to the complainant. The complaints procedure is displayed in the entrance area and is also contained in the written information provided to people using the service, or to their representatives. One person using the service currently has an external advocate, and arrangements can be made for any of the people using the service to benefit from this service. An outside agency has previously been involved in the residents’ meetings in an advocacy capacity, but the manager explained that the agency felt that it was not particularly beneficial to continue with the meetings. The manager is exploring the possibility of another outside agency taking up the advocacy role at these meetings. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 18 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): NMS 19,21,22,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, clean and suitably maintained care home. EVIDENCE: Relatives that we spoke with were satisfied with the facilities at the care home. One person commented that the home is always kept clean. We undertook a partial tour of the premises and found the home to be generally well maintained. Some of the wooden window frames are starting to deteriorate, but there is a programme to gradually replace these. Many areas of the home have been redecorated and refurbished during the past year. Replacement floor coverings are on order for some of the corridors. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 19 The building has been made secure for the client group, with key-coded fire exits, which release if the fire alarm system activates. There is a secured garden area at the rear of the care home for the use of the people using the service. The manager has undertaken risk assessments for the environment and for any procedures that could impact on the safety of the people living at the home. There are shower and assisted bath facilities for use by the people using the service. All of the radiators are of the low-surface temperature type, which promotes the safety of those living there. Staff had undertaken infection control training and we observed that they were using aprons and other protective measures appropriately during the time that we were undertaking the inspection, including during the mealtime. The manager stated that one of the staff acts as the home’s infection control link with the hospital infection control team, and that there are policies and procedures in place for infection control. A member of the hospital’s team has undertaken training sessions with staff at the home. The laundry is fit-for-purpose and feedback from relatives indicated that they were satisfied with the service. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 20 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): NMS 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. Staff training and recruitment practices promote the safety of people living at the home. EVIDENCE: The self-assessment completed by the home states that staff have access to a comprehensive training package and that a training matrix is used to help coordinate the training programme. We sampled the recruitment files of two staff employed at the home. The records that we examined contained satisfactory evidence to support that the home is carrying out the appropriate pre-employment checks before staff commence working at Clumber Court. Relatives and staff that we spoke with felt that there was generally sufficient staff on duty at any one time to meet the needs of the people living at the home. We spoke with the manager and with staff about the training programme at the home. Staff receive a range of training on a rolling programme, including Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 21 mandatory training. The manager informed us that approximately sixty-five percent of staff had undertaken National Vocational Qualification (NVQ) Level 2 and Level 3 training. A further eight staff have signed up for NVQ training, but have not yet commenced. Induction and training records are held for each member of staff and we examined a sample of these. Staff undertake a twelve-week induction programme and only work unsupervised when all mandatory training has been completed. We also had sight of the training matrix, and the summary sheets, which show the percentage of staff that have received particular training. The documentation supports that staff receive a range of training to promote the safety and wellbeing of the people that live at the home. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 22 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): NMS 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 health, welfare and safety of people living at the home are promoted by the management systems in place. EVIDENCE: A manager registered with the Commission for Social Care Inspection leads the home. The manager has a nursing qualification and has also undertaken a relevant management qualification (Registered Managers Award). There was positive feedback from staff, relatives and the General Practitioner that we spoke with about the way that the home is managed. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 23 We looked at the quality assurance and quality monitoring systems in place at the home. The manager confirmed that mandatory monthly visits by the provider/representative (Regulation 26 visits) were taking place, with reports compiled from each visit. These regulatory visits are part of the quality monitoring processes, which are meant to act in the interests of the people living at the home. There are regular audits of key aspects of the service. The audits that the manager undertakes include catering, medications, accidents, complaints and pressure ulcer prevalence. Periodic surveys of service user satisfaction are undertaken. However, the manager told us that the response rate from the last survey was too small to allow analysis of the findings. The manager is giving consideration to how the response rate can be improved for the next satisfaction survey. A three-monthly newsletter is produced as part of the communications mechanisms with relatives and representatives. We looked at the record keeping system for the handling of personal money belonging to people living at the home (small amounts). The recording and checking system is satisfactory and is backed up by company audits. The accounts are individually linked to an external bank account, which enables the credit of interest on the separate amounts held. A dual signature receipt system is employed. The system in place safeguards the interests of the people who live at the home. Safe working practices data and maintenance/servicing documentation were examined on a sample basis, with consideration given to the information provided prior to the inspection in the AQAA self-assessment dataset. There was evidence that routine checks and maintenance of equipment/services is taking place. Staff receive mandatory training including fire safety, manual handling, and food hygiene. Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations The home’s care plan documentation processes should be further developed to demonstrate that the service fully considers individual capacity to take decisions, in accordance with the Mental Capacity Act 2005. Maximum and minimum temperature monitoring of the medication refrigerator on the residential unit should be undertaken to ensure the temperature does not exceed recommended parameters. 2 OP9 Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clumber Court Care Centre (Care Home) DS0000024636.V373650.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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