CARE HOME ADULTS 18-65
Clova House 97-99 Clova Road Forest Gate London E7 9AG Lead Inspector
Seka Graovac Unannounced Inspection 3rd October 2005 10:00 Clova House DS0000041147.V255079.R01.S.doc Version 5.0 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.V255079.R01.S.doc Version 5.0 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.V255079.R01.S.doc Version 5.0 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 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.V255079.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th April 2005 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 DS0000041147.V255079.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted approximately 3 and a half hours. The main aim of this inspection was to check the home’s progress towards achieving full compliance with legislation related to care provision. The inspector focused on the national minimum standards that were assessed as not met or partly met at the previous inspection and also on the key standards that hadn’t been inspected previously. The inspector conducted a partial tour of the home. She saw all the communal areas and all bathroom and toilet facilities. She spoke to the Registered Manager, several support staff and the cook. The inspector also had conversations with 6 service users. The following records were examined: statement of purpose and service user’s guide, medication records, staff files, service users’ individual files, complaints procedure and log, protection procedure and policy, food related records and fire-safety log. Out of ten requirements that had been made at the previous inspection, four had to be repeated. What the service does well: What has improved since the last inspection?
The inspector viewed the home’s statement of purpose and the service user’s guide. Both documents had been reviewed and were fully compliant with legislation in terms of the information included. Since the previous inspection, the home has developed a monthly activities programme in addition to the individual activities plans included in the service users’ files. All the complaints procedures have been amended so that they comply with legislation. New dining room chairs have been bought and some re-tiling has been done in the shower room. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 6 The fire-doors have been fitted with door-guards. Fire-safety related records have improved since the previous inspection. Staff support and supervision records have also improved. 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. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 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.V255079.R01.S.doc Version 5.0 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 the following standard(s): 1, 2 and 5. The information available about the home enabled service users to make informed choices. EVIDENCE: The inspector viewed the home’s statement of purpose and the service user’s guide. Both documents had been reviewed and were fully compliant with legislation in terms of the information included. The examined individual service users’ files contained comprehensive care and support needs assessments and terms and conditions signed by both parties. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 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 the following standard(s): All key standards related to Individual Needs and Choices were assessed as met at the previous inspection and were not reassessed on this occasion. EVIDENCE: Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 14, 15 and 17. The service users enjoyed their meals. The home had a monthly activities programme and encouraged service users to participate. The appropriate family and personal relationships were facilitated, but the home did not have a policy on sexual relationships. EVIDENCE: Since the previous inspection, the home has developed a monthly activities programme in addition to the individual activities plans included in the service users’ files. Various leaflets containing information about the activities in the community were also displayed in the communal areas of the home. The inspector was informed that the service users enjoyed a recent visit to Clacton on sea, City-farm and Pub-lunches. The Registered Manager stated that the service users were encouraged to maintain positive relationships with their families in friends in accordance with their wishes and needs. Legal aid was utilised to help a service user with complicated family dynamics. However, the home did not have a policy on sexual relationships. A statement about non-discriminatory attitudes regardless of sexual orientation was available.
Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 11 The service users told the inspector that they very much enjoyed food in the home. The menu was displayed in the dining area indicating balanced diet. Food was appropriately stored and all food related records seen by the inspector were appropriately kept. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18 and 20. The home continues to fail the national minimum standard regarding dealing with service users’ medication. This is of great concern for the Commission as it potentially could put service users’ health and wellbeing at risk. EVIDENCE: At the inspection, the medication room was found unlocked with the key hanging in the door. There was nobody in the room. Medication Administration Record Sheets were left on the top of the low cupboard and none of the cupboards were locked. The Medication Administration Records contained a number of gaps. The home did not sign for the receipt of medicines and did not keep stock records. The inspector noted the improvement in terms that the staff have stopped double dispensing medication for the service users since the previous inspection. However, the inspector was very concerned that the requirement relating to the home’s dealing with the medication had to be repeated yet again. The Registered Manager stated that none of the service users needed help with personal care. Some needed the encouragement and this was appropriately identified in the service user’s individual care plans and implemented. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 22 and 23. The service users were not fully protected by the home’s procedures. EVIDENCE: The policies and procedures regarding concerns, complaints and protection have been reviewed since the previous inspection. All the complaints procedures have been amended so that they comply with legislation. The Protection of Vulnerable Adults (POVA) procedure has also been reviewed and amended. However, the leading role of the Local Authority in the investigation of an allegation of abuse was still not clear to the management of the home. The Registered Person(s) investigated and dismissed a staff member without notifying either the protection department of the Local Authority Social Services or the Commission for Social Care Inspection. Once again, the inspector expressed her concern regarding the home’s dealing with the protection issue and repeated the related requirement. The Registered Manager stated that the owner of the service was planning to inform the appropriate Authorities at a later date. The inspector reiterated that the Local Authority must have the leading role in the investigation of protection issues and that the Commission must be notified without delay (within 24 hours of allegation being made). Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 24, 27 and 28. The environment must be better maintained in order to meet the National Minimum Standards. EVIDENCE: The inspector discovered a number of issues related to the environment. The ventilation was still inadequate in the laundry room despite some work being done to improve it. The ventilation also appeared not to be functioning properly in some of the bathrooms. The shower-heads had scale build-up. The banister leading to the top floor was broken. The dining table and the flooring in the kitchen were chipped. The home was not well maintained. The Registered Manager confirmed that the above problems had been reported and the home was awaiting a contractor’s visit. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. The service users were supported by competent and appropriately supervised staff. However, the recruitment procedure was not always thorough. EVIDENCE: The Registered Manager stated that out of 12 support staff, five staff achieved National Vocational Qualifications and one staff member was a qualified Social Worker. The staff were awaiting their qualification certificates at the time of the inspection. The examination of the staff files indicated that one-to-one sessions were held on a regular basis. Since the previous inspection, all the staff underwent their appraisals and assessment of their individual training needs. However, the training plan for the home was still outstanding and the related requirement was repeated. The inspector noted with concern that there was no evidence on one of the files about the Criminal Records Bureau check being done. The Registered Manager reassured the inspector that she herself saw the CRB document and would ask the staff member to bring it in. The evidence must be available on the staff files to confirm the appropriate checks being done. All examined staff files contained two references. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41 and 42. The home must do its utmost to safeguard confidentiality of service users’ individual records and fire safety. EVIDENCE: The Registered Owner visited the home on a regular basis and monitored its service. The Registered Manager stated that information regarding service users’ satisfaction was compiled but the report of analysis of the responses was not available. The report must be written and made available to service users, the Commission and other interested parties. Most of the required records were appropriately kept (see the rest of the report). The inspector noted that the minutes of the one-to one sessions with the service users were all recorded in the same bound book, thus potentially compromising access to confidential information. This was discussed with the Registered Manager and the related requirement was made. The inspector was also concerned that the fire alarm panel was not visible from the corridor and was kept in the locked cupboard with the key being kept in the locked office. In emergency, it would take more time needed to identify
Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 17 where the fire-alarm point was triggered then necessary. The inspector required that this to be reviewed. The inspector was informed that since the previous inspection door-guards connected with the fire-alarm system have been installed. The fire-log book indicated regular fire-alarm tests and drills as required. Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X 2 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Clova House Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score x x 2 X 2 2 X DS0000041147.V255079.R01.S.doc Version 5.0 Page 19 No 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 2 Standard YA15 YA20 Regulation 12 13 Requirement Timescale for action 31/01/06 3 YA23 13 4 YA24 23 The Registered Person(s) must develop and implement a Policy on Sexual Relationships. The Registered Person(s) must 31/10/05 ensure that the appropriate procedures for dealing with service users’ medication are fully implemented. The previous target for this requirement expired on 30/04/05. The Registered Person(s) must 30/11/05 ensure that the home’s policy and procedure for dealing with an allegation or evidence of abuse is reviewed so that is fully compliant with legislation. The procedure must be implemented at all times and all staff must receive the appropriate training. The previous target for this requirement expired on 31/05/05. The Registered Person(s) must 30/11/05 ensure that all areas of the home (including the laundry room) are adequately ventilated. The previous target for this requirement expired on 31/05/05.
DS0000041147.V255079.R01.S.doc Version 5.0 Clova House Page 20 5 6 7 YA24 YA24 YA27 23 23 23 8 YA34 19 9 YA35 18 10 YA39 24 10 YA41 17 11 YA42 23 The Registered Person(s) must ensure that the dining table surface is not chipped. The Registered Person(s) must ensure that the broken banister is repaired. The Registered Person(s) must ensure that the shower-heads in the home are free from limescale build-up. The Registered Person(s) must ensure that the evidence is available on the staff files to confirm the appropriate Criminal Records Bureau checks were done prior to the commencement of the employment. The Registered Person(s) must ensure that the home develops a training plan based on the individual staff training and development assessment/appraisal. The previous target for this requirement expired on 30/08/05. The Registered Person(s) must ensure that the service users views underpin the running of the home. The report based on the service satisfaction survey must be published and made available in the home. The Registered Person(s) must ensure that the home’s procedure for keeping individual service users’ records does not potentially compromise confidentiality of the records kept. The Registered Person(s) must ensure that access to the information on the home’s fire panel is reviewed so that the safest arrangement is put in place. 31/10/05 31/10/05 31/10/05 31/10/05 31/12/05 31/12/05 30/11/05 30/10/05 Clova House DS0000041147.V255079.R01.S.doc Version 5.0 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. Refer to Standard Good Practice Recommendations Clova House DS0000041147.V255079.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East London Area Office 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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