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Inspection on 06/09/05 for Clavering Nursing Home

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

This inspection was carried out on 6th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Choice and dignity are promoted by care staff, to improve quality of life of residents. Pressure sores are successfully managed in the home.

What has improved since the last inspection?

There were no requirements or recommendations arising out of the previous unannounced inspection. However, this has not led to complacency within the running of the home. Some new furniture has arrived, particularly, new easy chairs. There is now a new minibus and a permanent activities coordinator in post.

What the care home could do better:

There is an intention to have more outings for residents and further promote access to the local community. Some tidying up was needed in the communal garden area particularly by the exits at the back.

CARE HOMES FOR OLDER PEOPLE Clavering Nursing Home Royston Grove Hatch End Pinner HA5 4HE Lead Inspector Richard Adkin Unannounced 6 September 2005 10.45am 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 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 G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Clavering Nursing Home Address Clavering nursing Home Royston Grove Hatch End Pinner HA5 4HE 020 8421 5819 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Clavering Care Limited Mrs Milithra Wickramarachchi Care home with Nursing 49 Category(ies) of DE(E), MD(E) registration, with number of places Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Dementia - over 65 years of age. Mental Disorder, excluding learning disability or demntia over 65 years of age. Date of last inspection 1st March 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. There were 48 residents in the care home at the time of the unannounced inspection - one resident was in hospital and one resident was in a respite bed. 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 G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during the day on a weekday over five and a half hours with the emphasis on looking at the core standards. The inspector looked around the building and a number of records and policies were inspected. A number of residents, staff and visitors were spoken to. Several relatives said that the home was well managed and well run, and they were made most welcome. What the service does well: What has improved since the last inspection? What they could do better: Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 6 There is an intention to have more outings for residents and further promote access to the local community. Some tidying up was needed in the communal garden area particularly by the exits at the back. 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 G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 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 standard(s) 3 There is a proper assessment prior to people moving into the service ensuring that their care needs are understood. EVIDENCE: The inspector looked at the two most recent admissions including a respite care placement to Clavering Care Home and the background information on one of the two self-funding residents. The pre-admission assessment was comprehensive in covering the prerequisite areas of needs assessment. The assessment forms looked at were signed, dated and detailed. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 Arrangements are in place to ensure that the health care needs of residents are identified and met. EVIDENCE: The manager undertakes a care plan audit on a monthly basis covering comprehensiveness of recording and record keeping, assessment such as risk and lifting, life story work etc. Shortfalls in care plans are followed up by a memo to the relevant keyworker/associated nurse, discussed in supervision and relevant training organised. A number of policies were looked at by the inspector, in relation to the receipt recording, storage, handling administration and disposal of medicines. The policies viewed included: ’Prescription and verification of Drugs and Medicines’ ‘Safe storage of drugs, medicines and medical equipment’ ’Handling and use of household medicines’ Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 10 Administration of Drugs and Medicines to a service user’ ’Medication policy and procedures’. Al the policies were satisfactory. ’A drug audit was also viewed. There is a regular GP input from the local surgery. An optician visits the home every six months. A Chiropodist comes in every six weeks. Records are kept for every resident. For weight monitoring, these are monthly and more regularly if there is fluctuation. There is a falls screening tool in place. No-one self medicates in the home. Pressure sores are well managed and the pressure sore assessment tool is in operation and was inspected. Positive feedback was received from several relatives about the quality of care received. One carer felt there was ‘no better home in the UK’. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13, 14, 15 Social activities are well organised and provide interest for people living in the home. Relatives of residents are positively engaged. Meals offer a healthy and varied diet for residents. EVIDENCE: There was a varied activity programme in place with one member of staff having the designated role of coordinating this. There are in addition, three external part time people employed, two specialising in arts and crafts and one a trained sports therapist. An Aromatherapist also has a weekly session and a hairdresser was present during the inspection and this was positively viewed by residents spoken to. A light therapy sensory corner was being completed with the purpose of lowering agitation for people with dementia. Residents spoken to were positive about the meal that they were eating at lunchtime. Choice of food was available and appropriate, sensitive support was being given where necessary to enable some residents to eat their meal. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 12 The home now has a new minibus and the intention is to expand the range of outings. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16, 18 The complaints procedure must be more accessible to ensure that residents and their carers have confidence that their concerns will be acted upon. The Adult Abuse and Whistle-blowing policies need to be updated in order that the correct channels are followed to ensure that people living in the home are protected from abuse. EVIDENCE: The manager of the home kindly showed the inspector the complaints procedure leaflet. However, this was not available in several bedrooms inspected nor was there a flyer on the complaints procedure in the main reception area where there was a wide range of relevant notices. The inspector was assured by some relatives of residents that comments were taken on board by the Home. One carer said ‘this is a home where the manager deals with things that may arise’. Neither the Adult Abuse Policy or the Whistle-blowing policy had sufficient detail around the reporting process, i.e. completing Regulation 37 forms, informing CSCI with the area contact details and alerting the community worker or commissioning authority. There was a clear POVA training process in place at the home. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 21, 26 The décor of the home was of good standard. Some minor areas of appearance needed attention. EVIDENCE: The home felt clean, pleasant and hygienic and free of offensive odours. Some areas needed rectifying: The dog fouling on the communal lawn needs to be kept clear, along with the removal of rubbish. There was an incontinence sheet airing/drying on the grab rails by the communal garden that needed to be removed. The zimmer frames stored outside in the garden by the shed needed to be removed. The downstairs toilet seat which is stained needs to be replaced. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 15 A maintenance man was present who operates between two homes in the organisation and keeps on top of maintenance issues. He kindly supplied information that the last LFEPA report 10/11/04 stated that the Home met a satisfactory standard and the Environmental Health report 26/1/04 stated that the Home maintains a high standard. There were a number of new comfortable chairs in the living area. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The induction process for staff is sound and the skill mix of staff is reasonable for meeting the needs of residents. EVIDENCE: One carer felt that there had been a turnover of staff that led to some inconsistency in care provision. The manager provided details of the rota going back a number of months which showed some stability in the workforce of about 50 staff. There are at least two qualified nursing staff on during the day and one at night. The selection and recruitment of staff policy was updated in March 2005. Two staff files were looked at which included statements of terms and conditions, evidence of satisfactory CRB checks and two written references. The induction process is six weeks. Care induction values cover privacy, dignity, independence, choice, rights fulfilment, empowerment, respect, individuality etc. Positive comments were received from staff spoken to about the induction process and ongoing training available. Every staff member goes on a TOPSS foundation course. There is a dedicated training room at the home. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 38 The home is well managed and led with guidance and direction given to staff to ensure residents receive consistent quality care. EVIDENCE: The home is led by an experienced manager. The manager undertakes a number audits on the key areas such as care plans, medicines, food, cleanliness, staff job satisfaction. The results of these audits are analysed and displayed. Good communication is promoted by the manager with carers and relatives etc. Regular meetings take place with relatives. An annual open day is well attended (30 relatives on the last occasion.) Several carers spoken to said that they felt most welcome. The newsletter was also seen by carers as a successful means of communication. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 18 The administrator deals with the finance of residents and the next of kin receives a statement of transactions. Only one resident holds his own money. The accounts book was well presented on inspection. Transactions were for hairdressing, outings, newspapers etc. Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 x 15 x COMPLAINTS AND PROTECTION 2 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 4 x 3 x x 2 Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 20 None Are there any outstanding requirements from the last inspection? 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. The Adult Abuse and Whistleblowing policies need to be updated and include details about contacting CSCI and contacting the referring agency. The dog fouling on the communal lawn needs to be cleared along with the removal of rubbish. The incontenence sheet airing/drying on the grab rails by the garden to be removed. The zimmer frames stored outside in the garden by the shed need to be removed. The downstairs toilet seat which is stained needs to be replaced. A warning sign is needed for the step down to the staff changing room. Timescale for action 1 November 2005 1 November 2005 Immediate action taken. Immediate action taken. 1 November 2005 1 November 2005 1 November 2005 2. OP18 13 3. OP19 23(2)(o) 4. 5. 6. 7. OP19 OP19 OP21 OP38 23(2) 23(2) 23 (2) 23 Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 21 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 Good Practice Recommendations Clavering Nursing Home G62-G11 S57551 Clavering NH v234227 060905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 4th 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. 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