CARE HOME ADULTS 18-65 Clova House 97-99 Clova Road Forest Gate London E7 9AG
Lead Inspector Seka Graovac Announced Inspection 11th April 2005 at 10:00am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Clova House Version 1.10 Page 3 SERVICE INFORMATION
Name of service Clova House Address 97-99 Clova Road, Forest Gate, London, E 9AG 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) 020 8281 7413 020 8281 7452 Simiks Care Limited Ms Annette Ajufo Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Clova House Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18th November 2004 Brief Description of the Service: Clova House is a care home for adults with mental health care and support needs. The home is privatelly owned by Simiks Care Limited. It is registered with the Commission for Social Care Inspection to provide the service to up to eleven people between the ages of eighteen and sixty-five. The premises are situated in a residentail area of Forest Gate in Newham, close to public transporrt and other community amenities. Parking on the road is not restrected. Clova House Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. At the previous inspection that was conducted unannounced in November 2004, thirteen requirements were made. The main aim of this announced inspection was to monitor the home’s improvement of the service delivered to its service users in accordance with the National Minimum Standards and the Care Homes Regulations. The inspection took place over approximately six hours and included the group discussions with the service users and staff as well as the individual interviews with the registered manager and one of the staff who was on duty on that day. The inspector also had a partial tour of the home and viewed various service users’ and staff records (three of each were randomly selected). Other home’s documents were also read as part of the inspection process. Via the Commission’s comment cards, written feedback was received from six service users, seven staff members, two relatives and one visiting psychiatric nurse. All these different methods informed the inspector’s judgements about the home. This inspection identified ten breaches (including two restated ones) of care related regulations. The inspector was particularly concerned about the identified issues related to medication recording and the procedure for dealing with an allegation or evidence of abuse. But as the home performed really well in some aspects of the service, the inspector formed a view that Clova House did have the capacity to secure full compliance with the National Minimum Standards and the Care Homes Regulations within the targets set in this report. What the service does well:
The prospective service users’ care and support needs were assessed prior to the admission being agreed. The comprehensive individual care plans were drawn up and were regularly reviewed. The individual risk assessments that included guidelines for challenging behaviour and pre-warning signs were particularly good. The service users’ independence and choices were respected in accordance with their needs and the identified risks. All the agreements reached in respect to the service users’ care were signed by both parties. The service users’ and the staff meetings were held on a regular basis. The manager has achieved the Registered Managers Award and was working towards Masters in Health and Social Care Management. The home was clean. Clova House Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office.
Clova House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Clova House Version 1.10 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, and 5. The information provided to the prospective service users’ in the home’s statement of purpose and service user’s guide has to be further improved in order to enable people to make fully informed choice. The assessments of the service users’ care and support needs were comprehensive and the contracts were signed by both parties involved. EVIDENCE: The inspector viewed the home’s statement of purpose and service user’s guide and discussed their content with the manager. Following the related requirements being made at the previous inspection, both documents were reviewed in January 2005. However, some required information was still not included. For example it was not mentioned how the inspection reports of Clova House could be accessed. The viewed service users’ files contained comprehensive individual care and support needs assessments carried out by the mental health professionals external to the home, as well as the home’s own ones. The service users’ files also contained costed terms and conditions/contracts that were signed by themselves and the manager on the behalf of the service provider. Clova House Version 1.10 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. The service users’ independence and choices were respected in accordance with their personal care plans and the individual risk assessments. EVIDENCE: The viewed service users’ files contained comprehensive individual care plans that were regularly reviewed within the CPA approach. The reviews included input from the external mental health professionals, as well as the service users themselves, their relatives and the staff from the home. The individual risk assessments were in date. The guidelines for managing challenging behaviour that identified the pre-warning signs for the particular individual and was also used to monitor the effect of the staff actions were available in accordance with the home’s policy on managing violent and aggressive behaviour. All viewed documents were signed by both parties. This also included the receipt of the service users’ guide. Some service users benefited from Newham Mental Health Advocacy. One service user benefited from legal aid through the Legal Services Commission. The inspector observed the service users moving freely around the house and engaging in the activities of their choice. The home was flexibly run.
Clova House Version 1.10 Page 10 The service users’ meetings were held on a regular basis and the minutes were available for inspection. Clova House Version 1.10 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 16 and 17. The service users enjoyed their meals and led active lifestyles in accordance with their interests and choices. However, the recording and planning of activities organised by the home could be improved. EVIDENCE: One service user attended her English language class on the day of the inspection. Another service user was out being engaged in a gardening project. The inspector was informed that the home’s garden at the back of the house was maintained by the same service user. Various leaflets containing information about activities in the community were displayed in the communal areas of the home. The inspector attended a discussion group organised and led for the service by the staff. The group was themed around current affairs and the forthcoming elections. All viewed service users’ files contained their individual activities plans. The inspector was also told that the service users went on a day trip to Southend in a week prior to the inspection.
Clova House Version 1.10 Page 12 However, the programme of activities organised by the home was not available. The only records of the activities already done were through the expenditure records. A staff member made the inspector aware that sometimes it was difficult to motivate the service users to engage in the activities. However, she demonstrated her commitment to encourage the service users to do so and her understanding of the significance of the service users ‘ involvement in the activities for their wellbeing and development. There was plenty of food in the home on the day of the inspection. The food was appropriately stored and labelled and the appropriate records were kept. The cook was preparing meat-balls in tomato sauce with spaghetti and green vegetable in accordance with the menu that was displayed in the kitchen/dining room.” Eat well” leaflet produced by NHS was also displayed. The inspector was informed that the service users discussed the menus at their monthly meetings and got engaged in cooking on occasions, usually on Sundays. Clova House Version 1.10 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 21. The inspector identified the issues with the home’s dealing with medication that might impact on the service user’s safety and potentially put them at risk. The home had a good liaison with the other health and social care professionals and the service users’ health needs were otherwise met. The service users wishes in regards to their own death were recorded. EVIDENCE: The service users ‘ medicines and the related records were kept in a separate locked room in the locked wall-cabinets. The inspector was concerned that the home’s medication stock records were not appropriately kept. The system used was confusing to say the least and it meant that it was very difficult to carry out the appropriate checks. In two instances the medicines received in the home were recorded but the names of the service users who they belonged to were not. At first, the manager had given the incorrect information to the inspector in regards to whom this medicine was for and then corrected it later. Receipt of many tablets were not recorded anywhere. The staff were doubledispensing the medicines for the service users. The inspector expressed her concern that not following the appropriate procedures in regards to dealing with service users’ medication might put the service users at risk. The content of the service users’ files indicated that the service users had access to different mental and physical health and social care professionals in accordance with their needs and that those needs were met.
Clova House Version 1.10 Page 14 Since the previous inspection, the home has developed and implemented the policies and procedures on Ageing, Care of the Dying (including Palliative Care) and Death of Service User. The service users files contained records of the discussions held with them in this respect and their wishes and choices. Clova House Version 1.10 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The service users rights to complain and be protected from abuse were potentially compromised by the inadequacy of the related policies and procedures in the home. EVIDENCE: The complaints procedures that the inspector saw (one displayed on the wall, one from the policies file in the office and one included in the statement of purpose and the service user’s guide) were not consistent in their content regarding the complainant’s right to get the Commission for Social Care involved at any stage. The home’s policy on protection of vulnerable adults did not refer to Social Services and “No secrets” document. The manager was not aware that any allegations of abuse had to be reported to Social services and that the Social Services would be directing the investigation. However, protection of service users was a regular item on the staff meetings and staff were receiving training in this area through their National Vocational training. Clova House Version 1.10 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. The service users appeared comfortable in the environment that was clean and generally well maintained. However, there were some issues with ventilation in the home. The bath and toilet facilities significantly improved since the previous inspection. EVIDENCE: The inspector was informed that in accordance with the requirements made at the previous inspection, the following improvements have been done to the environment: new sofas were bought for the communal lounge, new flooring (either ceramic tiles or laminated wood) was fitted to some bathrooms, toilets, the entrance hall and the communal hall in the basement. Some toilet sits have been changed. The home has also employed a designated cleaner and was clean at the time of the inspection. The inspector noted that there were not enough dining chairs if the service users wanted to have their meals at the same time. The manager stated that in that case the garden chairs would be brought in. The inspector also noted that ventilation was not appropriate in the home’s laundry room. The inspector’s glasses were all steamed up when she entered this room. The hot air from the drier was blowing into the room that did not have any windows. The manager claimed that the ventilation box on the ceiling
Clova House Version 1.10 Page 17 was working. The inspector was not convinced, but was unable to check. However, even if that was the case, the ventilation was clearly inadequate. The whole room was full of hot steamed air. The inspector saw three service user’s bedrooms that were of appropriate size and reflected their occupants’ interests and lifestyles. Two pay-phones were located in the communal areas of the home, thus compromising the privacy of phone-calls. However, this was resolved by clearly stating in the service user’s guide that the service users would be allowed to make private phone calls using the office phone. Clova House Version 1.10 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. The recruitment process was thorough but the service users could benefit from staff whose training and supervision were more systematic. EVIDENCE: The inspector viewed files for three staff who were on duty on the day of the inspection. The records indicated that the recruitment procedure was thorough. The support and supervision meetings’ minutes kept on the files indicated that their frequency did not meet the National Minimum Standard. None of the files contained information about the appraisals, although the manager stated that they were happening on a regular basis. The training plan for the home was not available, although the home did keep the record of the training attended by the staff and it was evidenced that the staff training needs were discussed. Clova House Version 1.10 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40 and 42. This inspection identified ten breaches of care related regulations. As the home performed really well in some aspects of the service, the inspector formed a view that Clover House did have the capacity to secure full compliance with the National Minimum Standards and the Care Homes Regulations within the targets set in this report. EVIDENCE: The manager obtained the Registered Manager Award and also had a first level degree in Psychology. She was experienced in care management and was also working towards masters degree in Health and Social Care Management. The inspector observed the service users freely entering the manager’s office and relating to the manager with ease. The service users’ and the staff meetings were regularly held. The service users were involved in the recruitment of staff. Their and their representatives’ views informed the individual reviews of the placements that were also happening on a regular basis. Since the previous inspection, the home has developed a satisfaction survey protocol and
Clova House Version 1.10 Page 20 was in process of implementing it. The report on findings based on the analysis of the completed questionnaires was still not available. The provider visited the home on a monthly basis and forwarded the monitoring reports to the home. The inspector randomly selected a number of policies and procedures that are included in the Appendix 2 of the Care Homes Regulations. All of them were available in the home and seemed appropriate (apart from the ones already mentioned in this report). Records viewed in regards to health and safety of the home were in date. However, the inspector was concerned that the fire-doors were kept open propped with the wedges. The fire risk assessments were in date and the other related records evidenced regular weekly fire-alarm tests and fire drills. However, the time and the names of the people participating in them were not recorded. The inspector was informed that an administrator has been employed to help with the administration of the home since the previous inspection. Out of thirteen requirements made at the previous inspection, two had to be repeated. Eight new requirements were made at this inspection, totalling ten breaches of regulations. SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2
Clova House Score 2 3 Standard No 22 23
Version 1.10 Score 2 1
Page 21 3 4 5 x x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 4 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 1 4 Standard No 37 38 39 40 41 42 43 Score 3 x 2 3 x 2 x Clova House Version 1.10 Page 22 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 1 Regulation 4 Requirement The registered person(s) must ensure that the homes statement of purpose is reviwed and amended so that it contains all the information as listed in the Schedule 1 of the Care Homes Regulations. ( The previous target not expired and repeated.) The registered person(s) must ensure that the service users guide is revewed and amended so that either includes the latest inspection report or the information how it could be accessed through the home. The registered person(s) must ensure that the appropriate procedures for dealing with service users medication are fully implemented. This includes the appropriate stock records. (The previous target expired on 18/11/04.) The registred person(s) must ensure that all forms of the homes complaints procedure are consistent in stating the complainants right to refer the complaint to the Commission for Social Care Inspection at any
Version 1.10 Timescale for action 30/04/05 2. 1 5 31/05/05 3. 20 13 30/04/05 4. 22 22 31/05/05 Clova House Page 23 stage. 5. 23 13 The registered person(s) must ensure that the homes policy and procedure for dealing with an allegation or evidence of potential abuse is reviewed and amended so that it is fully compliant with legislation and Department of Health guidance No secrets. The policies and procedures must be fully implemented at all times and all staff must receive the appropriate training. The registered person(s) must ensure that all ares of the home (including the laundry room) are adequatelly ventilated. The registered person(s) must ensure that there are enough dining room chairs so that the service users could all eat at the table at the same time if they wished to do so. The registered person(s) must ensure that the home develops a training plan based on the individual staff training and development assessment/appraisal. The registered person(s) must ensure that each staff member receives a minimum of 6 support and supervision meetings a year and that the records are available to evidence that. The registered person(s) must ensure that the fire-doors are either kept shut or fitted with the approved devices connected to the fire-alarm system. 31/05/05 6. 24 23 31/05/05 7. 24 23 30/06/05 8. 35 18 30/08/05 9. 36 18 31/05/05 10. 42 23 11/04/05 11. Clova House Version 1.10 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 14 39 42 Good Practice Recommendations Develop a plan of activities organised by the home and keep the record when they take place and who attended. Produce a report based on the analisis of the completed satisfaction questionnairs. Record the time of the fire-drills and the names of the people who participated. Clova House Version 1.10 Page 25 Commission for Social Care Inspection 4th Floor, Gredley House 1-11 Broadway, Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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