Inspection on 28/07/08 for Clova House

This inspection was carried out on 28th July 2008.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clova House 17/05/07

Clova House 09/06/06

Clova House 03/10/05

Clova House 11/04/05

Clova House 18/11/04

Clova House 01/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Clova House 97-99 Clova Road Forest Gate London E7 9AG Lead Inspector Sarah Greaves Unannounced Inspection 28 and 31st July 2008 13:00 th Clova House DS0000041147.V361683.R01.S.doc Version 5.2 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 Clova House DS0000041147.V361683.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 Adults 18-65. 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. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clova House Address 97-99 Clova Road Forest Gate London E7 9AG 020 8281 7413 020 8281 7452 clovahouse@hotmail.co.uk 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) 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 DS0000041147.V361683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 2007 Brief Description of the Service: Clova House is a care home for adults with mental health care and support needs, and Simiks Care Limited owns it. The service is registered with the Commission for Social Care Inspection to provide care and accommodation for to up to eleven people between the ages of eighteen and sixty-five. The premises are situated in a residential area of Forest Gate in Newham, close to public transport and other community amenities. Parking on the road is not restricted. Clova House DS0000041147.V361683.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 1 star. This means that people who use the service experience adequate quality outcomes. This unannounced key inspection was conducted over two days. We gathered information through speaking to the residents, staff and the registered manager; there were no personal or professional visitors at the care home during the inspection. We read three randomly selected care plans, including information received from medical, health and social care professionals in order to ascertain if the service was able to work in a cohesive and productive manner with other parties involved in the care of individuals. We toured the premises and checked the storage of medication. We looked at a selection of the service’s documents, including policies and procedures, staff files for training, supervision and recruitment, and health and safety records. The service was sent a self-audit questionnaire known as an Annual Quality Assurance Assessment (AQAA) prior to this inspection. Information from the AQAA was used for the production of this report. It should be noted that there has been a change of service provider since the last inspection. This change occurred a few weeks before this unannounced inspection; therefore the new service provider has inherited issues that were not satisfactorily managed by the previous service provider. What the service does well: The service provides supportive care to the residents. Through discussions with residents and through reading a selection of the care plans, we found that the needs and aspirations of the residents were understood. For example, some people expressed that they hoped to lead more independent lives; hence staff were preparing people for tasks such as budgeting and undertaking domestic chores. It was also noted that a move to independent living was not currently appropriate for all residents, therefore people were being supported to steadily build upon their confidence and gain fulfilment through acquiring new skills. The care plans and risk assessments were of a good standard and there was a keen focus upon involving residents with constructive hobbies and interests. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Clova House DS0000041147.V361683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents (and their representatives) are provided with information about the service, and their needs are properly assessed. EVIDENCE: We read the service’s Statement of Purpose and Service User’s Guide. A recommendation had been issued in the previous inspection report for the Service User Guide to clarify that a member of staff with a social work qualification was not being employed in the capacity of a registered social worker (the person is employed as a part-time support worker); this recommendation was met. We observed on the first day of this inspection that some minor amendments were needed to these documents; for example, a flow chart indicated that the service employed two team leaders but the registered manager confirmed that this was not correct. We noted on the second day of the inspection that the service had addressed identified issues within the Statement of Purpose and the Service User’s Guide. We read three care plans during this inspection, including a care plan for a resident that was admitted since the last inspection visit in May 2007. We Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 9 found that the needs of residents were fully assessed by their placing authority and the service prior to moving in for a trial period. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported with their identified needs (including their entitlement to take informed risks) through effective consultation and care planning. EVIDENCE: We found that the three care plans read during this inspection were well written and up-to-date. The identified needs and aspirations of individuals corresponded with their multi-professional assessments (for example, information gathered from external medical, health care and social care practitioners) and the minutes of recent Care Planning Approach (CPA) meetings. The care plans were signed by the residents to demonstrate that objectives had been discussed and agreed. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 11 One of the care plans demonstrated that a resident was being supported with budgeting their finances (including a ‘savings agreement’ between the resident and their key worker); through speaking to the resident and reading information from external professionals, we found that this was an important element of supporting this person to pursue a more independent lifestyle. A resident informed us that they were progressing with language and literacy classes, which was encouraged by the service. Each care plan read during this inspection contained suitably presented risk assessments, which were regularly reviewed. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to engage in fulfilling activities and maintain links with their family, friends and local community. Although improvements are noted with the planning and delivery of the food service, findings at this inspection indicate that staff would benefit from specific training to develop catering knowledge. EVIDENCE: We gathered information through speaking to residents and the registered manager, as well as reading care plans and the minutes for residents’ meetings. The service arranged a weekly entertainment for residents; events in the past couple of months included visits to the National Gallery, the Natural History Museum, an Indian restaurant, bowling, a barbeque and the cinema. The purpose of these weekly outings was to enable people to develop their Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 13 confidence and self-esteem through engaging in different activities with other residents and members of the staff team. Residents were encouraged to use local leisure facilities such as the library, swimming pool and the gym, as well as amenities such as the post office, shops and cafes. Residents informed us that they were involved in a range of activities that offered opportunities for personal development and/or relaxation, such as piano lessons, cultural associations (an African-Caribbean project, an Asian women’s group and a Ugandan club) and a college based course for employment in the construction industry. People also attended a music group (we observed that a couple of the residents were playing their guitars during the course of this inspection) and other local drop-in activities for people with mental health needs. The service produced a satisfactorily written visitors policy; residents were permitted to receive visitors at the care home. We noted that residents also visited their friends and family members. It was noted that the care home was appropriately supporting a resident to have contact and outings with family members, which was very important for the well being of the resident. We found that the service promoted the civic rights of the residents; for example, people were encouraged to pursue their own interests and routines. The care plans indicated that discussions would take place with a resident, their representatives and involved professionals if any individual choices were actually or potentially harmful to the resident’s welfare and safety. A requirement was issued in the previous inspection report for the service to ensure that the menu plans provided sufficient detail regarding the content of meals and snacks, in order to enable any persons inspecting the menu to determine whether residents received a balanced and healthy choice. It was noted at this inspection that the menus were now more descriptive and there was a clearer emphasis upon fresh fruits. Residents informed us that they would like to have the option of cooked breakfasts more frequently; we found that the cooked breakfasts were available twice a week on a Sunday and a Monday. We wondered whether residents might prefer the two cooked breakfasts to be more evenly spaced over a week, which could be discussed at a residents’ meeting. We noted that the member of staff employed to prepare meals stated that he was not sure about offering more opportunities for residents to have cooked breakfasts because this option could be unhealthy and lead to unnecessary weight gain. We discussed this finding with the registered manager in order to explore whether foods could be prepared in a healthy manner (for example, grilling, poaching and scrambling instead of frying, the purchase of reduced fat sausages and other items, and adding healthy choices such as tomatoes, baked beans and mushrooms). The person employed to cook meals had not received any specific catering training for this role, apart from the mandatory food-handling certificate. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 14 Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the service demonstrated systems to address the health and personal care needs of individuals, the need for some improvements have been identified (disposal of medications no longer required and the timely delivery of relevant health care training for staff). EVIDENCE: The care plans identified that the personal care needs of the residents were identified, assessed and monitored as part of the care planning process. It was noted that one of the care plans identified that a resident needed to be prompted to have a shower three times each week, on a Tuesday, Friday and Saturday. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 16 A requirement was issued in the previous inspection report for the service to ensure that staff received training to meet the health care needs of residents with diabetes (this applied to two residents at the time of this inspection). This requirement had been issued in the last report, as we believed that staff needed to understand current ‘good practices’ related to the care of people with diabetes; the requirement was due to be met by August 2007. It was noted that the requirement had not been met at the time of this inspection, although we were informed on the second day of this inspection that training had been arranged for August 2008. The service had not contacted the Commission for Social Care Inspection in August 2007 to state that it had not been able to meet the requirement within the agreed timescale. Via discussion with the registered manager, we were informed that the service supported people to attend medical appointments as necessary and staff always accompanied residents to the Care Planning Approach (CPA) meetings. We checked the storage and administration of medication. It was noted that medication administration records were clearly presented and appropriately completed. However, we found medication that needed to have been sent back to the pharmacist, including a painkiller that was dispensed in August 2007 and was no longer prescribed for the person. At the time of this inspection none of the medication needed special storage arrangements such as refrigeration. We noted that there was no blind or curtain on the window in the medication room, which meant that passers-by on the street could observe staff dispensing medication. We were concerned that this could place residents and staff at risk and have asked the registered manager to promptly remedy this as part of the forthcoming environmental improvements to the premises. A recommendation was issued in the previous inspection report for the service to update its ‘Death and Dying’ policy; this was not evidenced. We spoke to the registered manager regarding the impact of ‘End of Life’ strategies, which General Practitioners and/or the local Primary Care Trust could advise upon. ‘End of Life’ was not mentioned within the ‘Death and Dying’ policy. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the service demonstrated that there were systems in place to listen to and respond to concerns, residents would benefit from receiving support from staff that undertook regular training to safeguard vulnerable adults. EVIDENCE: We looked at the service’s complaints procedure, which was clearly written and was made available to residents (and their representatives) within their Service Users Guide. There were no issues of concern relating to the management of complaints. Information was provided to residents regarding local independent advocacy services that they could contact. The service produced a satisfactorily written Adult Protection procedure; however, the service had not delivered Adult Protection training for over two years. The registered manager was advised to consider the provision of Adult Protection refresher training every year. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The appearance of the environment did not promote a welcoming, comfortable and homely experience, and there was an unacceptable lack of hygiene. However, the service clearly demonstrated its commitment to improvement during this inspection. EVIDENCE: We observed that the standard of the environment was very unacceptable on the first day of this inspection. It was noted that improvements, such as painting, repairs to existing fittings and the provision of new furniture and carpets (or flooring) were needed to the communal areas and the bedrooms. It was noted that one of the lounges had torn furniture (armchairs and a sofa) and needed to be repainted. We observed that the service had addressed the identified issues of concern in the lounge on day 2 of this inspection. Similarly, improvements had been made to the rear garden, some bathrooms and bedrooms and the laundry room during the course of this inspection. We found Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 19 that although the service had acted very promptly, there was consultation with residents for new colour schemes. The registered manager has been advised that the environment would otherwise have been assessed as being of a poor quality; however, the efficient response of the new provider had positively impacted upon the physical condition of the premises and it is hoped that ongoing progress will be achieved. We were informed that ten out of the eleven residents living at the care home at the time of the inspection were smokers. Smoking was not permitted within the building; however, we observed residents smoking in the lounge, in their bedrooms and on the stairway. It was noted that residents would need a covered area in the garden for smoking, to protect them from harsh weather conditions (such as rain and snow). Other improvements needed to be achieved, such as the provision of new net curtains in bedrooms and the restoration of toilets with unsightly exposure of enamel. We were informed that the service did not have a cleaner at the time of this inspection, although the position of a cleaner was identified on the staff flow chart provided to prospective residents and their representatives. The registered manager stated on the second day of this inspection that the prompt appointment of a cleaner had been agreed with the service provider. We found that the absence of a cleaner had very visibly impacted upon the cleanliness of the premises; for example, a thick layer of dust was observed on a windowsill. The unpleasant odour within the premises was due to a blend of different cigarette aromas. There was a notice on display on the first day of this inspection that informed residents that they could smoke in their bedrooms but the registered manager removed it, as this information was inaccurate. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the residents were addressed through providing sufficient staff that benefited from good supervision and a training programme; however, a more detailed approach to individualised training needs to be developed. EVIDENCE: Evidence was produced to demonstrate that staff were provided with induction training and were offered opportunities to undertake National Vocational Qualifications (NVQ) in Care at levels 2 and 3. More than 50 of staff had attained a minimum NVQ qualification. We found that the staff rota evidenced that sufficient staff were rostered on day and night shifts; the number of staff was increased on the day each week that staff supported residents to visit a local or Central London entertainment. We looked at three staff files, including two files for staff that were appointed since the last inspection. Recruitment was satisfactory, although we identified Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 21 one case in which the registered manager could have justifiably sought a third reference from a UK based organisation to accompany the two overseas references that had been obtained. The registered manager was also advised to follow –up the receipt of evidence regarding a qualification that a member of staff had stated that they had obtained. The service presented a training plan; however, we were of the opinion that this plan could be improved upon. For example, one of the training sessions was described as ‘Mental Health Awareness’, which would be very appropriate for relatively new staff at Clova House but this should be considered as an introduction to working with people with mental health needs. We would like to see more experienced staff being offered opportunities to access training that focuses upon the specific needs of residents at the service, such as ‘understanding the needs of people with schizophrenia’. The staff files evidenced that staff received regular one-to-one supervision of a suitably detailed quality. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the care home demonstrated that it consulted the residents in order to improve the service, certain findings at this inspection have indicated that the safety and environment for the residents was not consistently maintained at an acceptable standard. EVIDENCE: The service has been subject to a significant change since the last inspection in May 2007. A new service provider took over shortly before this unannounced key inspection and it is acknowledged that improvements to Clova House will not be instantaneously achieved, although the service provider’s very prompt response to outstanding requirements and the issues of concern with the environment has been noted. We found that the monthly-unannounced Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 23 person-in-charge visits (the last available report was for May 2008 and had been conducted by the previous service provider) did not comprehensively address the improvements sought by the Commission’s inspection report. The neglect of the premises by the previous service provider has indicated that the service has not benefited from the on going monitoring and development that a care home needs, hence residents have not been provided with a physical environment that promotes their self-esteem, comfort and safety. This report has also identified that the registered manager has achieved some good outcomes, such as the care planning and activities for residents. We noted that the service conducted regular residents meetings and the comments/suggestions for menus, outings and leisure equipment were addressed. The service had conducted surveys in January 2008; although the registered manager was familiar with the responses there was no formal analysis of the comments in order to identify any relevant trends. A requirement was issued in the previous inspection report for the service to ensure that all opened food items were dated and labelled. We found at this inspection that eggs without an expiry date were in the refrigerator and frozen fish without a label (thought to belong to a member of staff) was in the freezer. The registered manager immediately discarded the frozen fish. We have decided on this occasion to repeat the requirement regarding the labelling of food items, taking into account that other items were labelled and staff mistakenly assumed that the eggs were stamped with the customary expiry date. Although very prompt actions were taken during the course of this inspection to address health and safety issues, we were concerned by our initial findings. For example, there were nails sticking out of a bench in the garden and there was a broken plug with exposed metal work behind it in a resident’s bedroom. Both of these issues were satisfactorily dealt with by day 2 of the inspection. The Landlord’s Gas Safety test was undertaken during the course of this inspection and the electrical installations check had been booked for the 14th August 2008. The portable electrical appliances testing were up-to-date and the service produced valid public liability insurance for an appropriate level of cover. Issues related to the water pressure were being addressed. A requirement was issued in the previous inspection report in regard to the need for the service to maintain a clean and hygienic kitchen; the standard of cleanliness was not acceptable at this inspection. For example, work surfaces were noticeably grubby and there was an accumulation of crumbs and food debris. Through discussion with the registered manager and with residents, we were notified that residents, including residents that have chosen to formally assist with preparing main meals, are now using the kitchen more actively. Therefore, a new requirement has been issued for staff to support residents with using the kitchen in a clean and safe manner. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 24 Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 25 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. 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000041147.V361683.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Clova House Score 3 2 2 2 2 X 3 X X 2 X Version 5.2 Page 26 YES 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 YA42 Regulation 13 (4) Requirement The Registered Manager must ensure that food items that require refrigeration are stored in the refrigerator and opened food items must be labelled with the date of opening. This is a repeated requirement. 2. YA20 13 (2) The Registered Manager must ensure that medication no longer required is promptly disposed of through return to the pharmacist. The Registered Manager must ensure that the premises are well maintained, in regards to decorations, furnishings and safety. The Registered Manager must ensure that the premises are hygienic and free from offensive odours. The Registered Manager must ensure that staff receive training to develop their knowledge of the specific mental health care needs of the residents. The Registered Manager must DS0000041147.V361683.R01.S.doc Timescale for action 31/10/08 31/10/08 3. YA24 23(2)(b) 31/12/08 4. YA30 16(2)(k) 31/10/08 5. YA35 18(1) (c) 30/06/09 6. YA42 13 (4) 30/11/08 Page 27 Clova House Version 5.2 ensure that the kitchen is maintained in a safe manner. Staff need to work with residents to implement a joint cleaning programme for the kitchen. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA17 YA21 Good Practice Recommendations The service should provide specific catering/nutritional training for staff with responsibilities for producing meals. The service should reflect ‘End of Life’ information in its Death and Dying policy. This recommendation was presented in the previous inspection report. Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Clova House DS0000041147.V361683.R01.S.doc Version 5.2 Page 29 - 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. 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