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Inspection on 27/02/06 for Clavering Nursing Home

Also see our care home review for Clavering Nursing Home for more information

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents are nursed and cared for by a staff team that have access to an extensive training programme, including NVQ Level 2 in care. Residents benefit from living in a care home that presents as being managed effectively.

What has improved since the last inspection?

The care home has complied with 6 of the 7 requirements arising from the previous unannounced inspection.

What the care home could do better:

One requirement remains outstanding with regard to the care home`s complaints procedure.

CARE HOMES FOR OLDER PEOPLE Clavering Nursing Home Royston Grove Hatch End Pinner Middlesex HA5 4HE Lead Inspector Ms Sue Barker Unannounced Inspection 13:45 27 February 2006 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 Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 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. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clavering Nursing Home Address Royston Grove Hatch End Pinner Middlesex HA5 4HE 020 8421 5819 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) alawrencersinghomes.uk.com Clavering Care Ltd Mrs Milithra Wickramarachchi Care Home 49 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Clavering Nursing Home is a registered care home providing nursing care and accommodation for a maximum of 49 older people aged over 65 years who have dementia or enduring mental disorder. The registered provider is Clavering Care Ltd. The Registered Manager is Mrs Milithra Wickramarachchi. The home is located in a quiet residential road in Hatch End. It is some distance to shops, pubs and other community, transport and leisure facilities in Hatch End. The home is situated on three floors. It has a passenger lift. The home offers single and shared bedrooms. The bedrooms are located on two floors. The home has a large garden to the rear that is well maintained and accessible through the building. There is an office in the attic along with a training room. There are three living rooms and a conservatory with a seating area. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second unannounced inspection the care home during the year commencing 1/4/05. The key inspection standards were assessed during both inspections. There were 47 residents living in the care home at the time of the unannounced inspection. The Inspector arrived in the care home after lunch. Residents were resting in the lounges or their bedrooms. One resident kindly advised the Inspector that they preferred to spend time in their bedroom. An ‘Activities Organiser’ is employed in Clavering Nursing Home who was to arrange for activities to take place later in the afternoon. The Inspector observed a member of staff conducting a gentle exercise session with a small group of residents who were sitting a semi-circle in the large lounge. A weekly diary of activities for residents was displayed in the care home. This included musical chairs, entertainments and a reminiscence work. One resident had celebrated their 100th birthday with a party. There are photos of residents’ various celebrations displayed in communal areas of the care home. There are information boards for residents’ orientation in the lounges. The unannounced inspection included a tour of the communal areas of the building and a small sample of bedrooms. The Inspector viewed areas of the building that had been redecorated and fitted with new carpet. Mrs Milithra Wickramarachchi updated the Inspector on the care home’s plans to build a smoking room for the care home. The Inspector was pleased to speak to a number of residents, staff and visitors to the care home. The Inspector received positive comments about Clavering Nursing Home in terms of the environment and food available. The quality of nursing and care available was also praised. One resident let the Inspector know that staff came when they rang the call bell in their bedroom. A number of residents described the care home to the Inspector as “good”. The Inspector would wish to thank those in Clavering Nursing Home for the assistance received during the unannounced inspection. The Inspector was made most welcome. What the service does well: Residents are nursed and cared for by a staff team that have access to an extensive training programme, including NVQ Level 2 in care. Residents benefit from living in a care home that presents as being managed effectively. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 6 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. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 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 Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key inspection standards were assessed at the previous unannounced inspection. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key inspection standards were assessed at the previous unannounced inspection. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key inspection standards were assessed at the previous unannounced inspection. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key inspection standards were assessed at the previous unannounced inspection. The Inspector followed up the requirements arising with Mrs Milithra Wickramarachchi. The Protection of Vulnerable Adults from Abuse policy had been amended as required. Various ‘Complaints’ procedure documents were viewed around the building and in residents’ bedrooms. Some still required updating to include the full contact details for the local Commission for Social Care Inspection office. One resident kindly advised the Inspector that they were aware of whom to talk to in Clavering, should they have any concerns or complaints. Since the last unannounced inspection 2 anonymous complaints about Clavering Nursing Home were received by the Commission for Social Care Inspection. These were forwarded to the Registered Provider, Clavering Care Limited, to investigate. The conclusions were that there was no evidence to substantiate the anonymous complaints. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key inspection standards were assessed at the previous unannounced inspection. Previous requirements in respect of the environment had been complied with. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Residents are nursed and cared for by a staff team that have access to an extensive training programme, including NVQ Level 2 in care. EVIDENCE: The Inspector discussed the care home’s training programme with Mrs Wickramarachchi and viewed the training programme. It was reported that all care staff are undertaking or have completed an NVQ Level 2 in care as required. 7 members of staff were enrolled onto NVQ training in January 2006. Consideration is being given to the creation to a senior nursing role in the care home in order to acknowledge levels of training and experience. Mrs Wickramarachchi indicated that the Skills for Caring standards are being applied to the care home’s staff induction. The Inspector viewed details of the care home’s training programme. This included training in dementia, medicines management, first aid and basic food hygiene. Further training in Protection of Vulnerable Adults was planned. The Inspector spoke with Mrs Wickramarachchi about whether nursing and care practice in the care home was influenced after staff had undertaken training in, for example, dementia. Mrs Wickramarachchi stated that discussion about nursing and care practice arises at the daily one-hour staff handover between shifts. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 Residents benefit from living in a care home that presents as being managed effectively. EVIDENCE: The Inspector met with Mrs Wickramarachchi during the unannounced inspection. Mrs Wickramarachchi spoke of some of the changes and updating that had occurred since the Inspector last visited the care home. The care home had no staff vacancies at the time of the unannounced inspection. Mrs Wickramarachchi has managed the care home for more than 2 years. Mrs Wickramarachchi spoke to the Inspector about her own training plans for the year. The Inspector noted examples of clear lines of accountability both within the care home and to the proprietorial organisation. Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 15 Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x x Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 22(5) Requirement A complaints information leaflet needs to be displayed and needs to include reference to contacting CSCI as necessary. (Previous timescale of 01/11/05 not met) Timescale for action 27/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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 Clavering Nursing Home DS0000057551.V269987.R01.S.doc Version 5.1 Page 19 - 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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