Inspection on 09/06/06 for Clova House

This inspection was carried out on 9th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clova House 28/07/08

Clova House 17/05/07

Clova House 03/10/05

Clova House 11/04/05

Clova House 18/11/04

Clova House 01/06/04

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Stacey Street Nursing Home

Delrose House Ltd

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Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Clova House 97-99 Clova Road Forest Gate London E7 9AG Lead Inspector Seka Graovac Unannounced Inspection 09 and 12th June 2006 10:15 th Clova House DS0000041147.V293523.R01.S.doc Version 5.1 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.V293523.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V293523.R01.S.doc Version 5.1 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.V293523.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Clova House is a care home for adults with mental health care and support needs. The home is privately 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 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.V293523.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It lasted approximately four hours and was conducted over two days. On the first day of the inspection the inspector interviewed one service user in private and spoke to two other service users. She also spoke to staff members who were on duty and viewed some policies and the individual files for three service users. As the Registered Manager was on annual leave on that day, the inspector returned on a different day to view the staff files, make additional checks and give feedback. The inspector also toured the communal areas and spoke to more service users on a second day of the inspection. What the service does well: What has improved since the last inspection? Out of eleven requirements made at the previous inspection, the home has secured compliance with nine of them. A statement on sexual relationships has been developed. The procedure for dealing with medication has been amended and fully implemented. The procedure for dealing with protection allegations has been amended. The ventilation in the laundry room has been improved. The broken banister has been repaired and the dining table was going to be replaced by the spare one. The training plan has been developed. The service satisfaction survey has become available. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 6 All individual service users’ records are now securely kept. The fire safety has improved. In addition to the above, the inspector was informed that the whole interior of the building has been repainted. The colours were chosen by the service users. 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.V293523.R01.S.doc Version 5.1 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.V293523.R01.S.doc Version 5.1 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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective service users’ individual aspirations and needs were assessed. EVIDENCE: The inspector checked individual files for three service users. Each of them contained a comprehensive care and support needs assessment that was written by the home’s staff. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 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): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users were supported in accordance with their needs and risks. The care plans must be regularly reviewed. EVIDENCE: All viewed service users’ files contained individual care plans. However, the inspector noted that one of them hasn’t been reviewed in the last twelve months, despite the court decision that significantly changed this person’s life. The Registered Person(s) must ensure that all individual service users’ care plans are reviewed on at least annual basis or sooner if there is a significant change. The service users who spoke to the inspector were satisfied with the service. Their independence was encouraged. The files also contained excellent individual risk assessments that were regularly reviewed. However, the inspector questioned if the staffing level on Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 10 the first day of the inspection would have been sufficient to provide the stated level of supervision and support. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 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 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 the service. Service users were encouraged to lead fulfilling lifestyles. EVIDENCE: The activities were discussed on a regular basis at the service users’ meetings. The home had a monthly plan of outings, as well as a weekly schedule of activities such as: cooking, dancing, watching videos and gardening in good weather. Some service users attended music, drumming, English language or computing classes in the community. One service users helped an organisation with their IT on a voluntary basis. The inspector was also informed that some service users went on a holiday to a sea-side resort in May 2006. The activities were well planned with the service users’ participation and recorded. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 12 A statement on sexuality and relationships has been developed since the previous inspection. The regime in the home was very flexible. The inspector had a discussion with the Registered Manager regarding healthy balance of control and freedom in a residential care setting. One service user’s mother tongue was Urdu. Her key-worker was able to communicate with her in this language. She was able to speak to the inspector in English. The cook, who also did support work was on duty at the time of the inspection. The menu was displayed on the board. The food was appropriately labelled and stored in the fridge. Temperature records were kept on a daily basis as required. The kitchen was clean, apart from the hood above the cooker that was greasy. The inspector was informed that when the extractor from the hood broke, it was substituted with the extractor box mounted on the wall above the cooker. The area was greasy at the time of the inspection. The inspector recommended that this is reviewed. The inspector was told that the dining table had been repainted since the previous inspection, but was starting to show new cracks. It was agreed with the Manager that she would arrange for the spare dining table to be bought into this kitchen where the service users ate. The home had another kitchen that was used for cooking activities that were becoming popular among service users. The service users commented positively about the food in the home. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users’ were supported to maintain and improve their physical and emotional health. EVIDENCE: The service users were independent in maintaining their personal care. Their physical and mental wellbeing was monitored and appropriate referrals were made when it was needed. The inspector saw two service users who were on leave from hospital stay. A psychiatric nurse visited the home to give a depot injection to a service user on the day of the inspection. The inspector checked the medication and the related records and did not find any discrepancy. This is a major improvement for the home following a pharmacist inspection. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users were safeguarded by the home’s policies and procedures regarding complaints and allegations. EVIDENCE: Procedures regarding the home’s dealing with complaints and protection issues were available. The inspector viewed the complaints-log that indicated that no complaints have been raised with the home since the previous inspection. The Commission has not been made aware of any concerns or complaints either. The procedure for dealing with allegations have been amended so that it clearly states referral to Safeguarding officers at the beginning of the process. The Registered Manager stated that apart from one new staff, all others received training in Protection of Vulnerable Adults. The staff who spoke to the inspector confirmed that she had the appropriate training. There have been no protection issues raised since the previous inspection. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 15 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, 26, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment was clean and tidy, but not secure. The mattresses and the shower-heads needed attention. EVIDENCE: The inspector was concerned that the main door was wide open when she arrived. She was able to enter the building unnoticed. When a staff member saw her, she only waved to the inspector and passed by. The inspector was later explained that some service users leave the door open. During the first day of the inspection, the inspector saw the door being left open on a number of occasions. This is seriously compromising security of the building and safety of people in it. The inspector noted that on the second day of the inspection, when the Manager was in the building, the entrance door was kept closed. The Registered Person(s) must ensure that the premises are secure at all times. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 16 The inspector saw all the communal areas of the home. All the areas were tidy and clean. A domestic staff was on duty. The Registered Manager stated that entire interior of the building was redecorated since the previous inspection. The service users were offered opportunity to decide on colours. Non-smoking lounge was painted in lilac. The inspector also spent some time talking with one service user in her bedroom. As her bed was not made, the inspector noted that this person’s mattress was torn on a number of places. The staff members told the inspector that this wasn’t the only mattress that needed to be changed in the home. The Manager confirmed that she was aware of the problem and was dealing with it. The Registered Person(s) must ensure that the mattresses in the home are checked on a regular basis and renewed when it was needed. Despite the requirement made at the previous inspection regarding the shower-heads being kept free form lime-scale build-up, this hasn’t been actioned. The requirement was repeated. There was waterlog at the back of the building caused by poor drainage and possible problems with the water pump in the building. The problem was resolved on the 09th of June 2006. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 17 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, 33, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The staff files lacked the evidence of the appropriate CRB checks and regular supervision. EVIDENCE: On the first day of the inspection, there were only three staff in the building. One of them was a domestic, one was a cook (who also did support duties in the home) and one was a support worker. Another support worker was on the roster, but she was out with the service user, escorting her to the hospital. The support worker was unable to tell inspector how many and which service users were on the premises. The service users had their own keys and went in and out as it pleased them. The staff told the inspector that the staff would go to the service user’s bedroom if he/she was not seen for four hours, unless previously arranged. One service user appeared unsettled at the time of the inspection. He was on leave from the hospital and refused to take his medication in the morning. On the second day of the inspection, in addition to the Manager and the Administrator being present, there were four support staff and the cook on duty. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 18 The staffing levels were discussed with the Manager. The inspector recommended that the staffing levels were reviewed in accordance with the level of supervision required by the service users and especially if the Manager was not on the premises. The inspector was informed that the home’s team leader left and the team consisted of eleven mental health support workers. Two of them were qualified social workers and five have achieved a National Vocational Qualification (NVQ) in health and care. Some staff were working towards their NVQ award. The training plan listing training offered until September 2006 was available. The Manager stated that the training plan would be updated following the annual appraisal of staff. The inspector viewed individual files for three support staff. The inspector was concerned that despite the requirement made at the previous inspection regarding appropriate Criminal Records Bureau disclosures, none of the files contained the evidence of the appropriate checks being made. The Registered Manager stated that the staff whose disclosure was not available, definitely had one and that the other staff who had disclosures but obtained via their previous jobs, have applied through Simiks Care Ltd. 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 staff files contained two references and the other required documentation, such as: identity check evidence. The inspector also noted that the one-to-one supervision meetings were not held on a regular basis. The Registered Person(s) must ensure that all staff receive at least six one-toone supervision sessions in twelve months and that the records are available to evidence that. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 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 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): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Registered Manager is experienced and qualified. She is currently doing MA in Health and Social Care. The adequate cover in her absence was discussed at the inspection. Since the previous inspection, the home conducted a satisfaction survey that included service users, care coordinators and relatives or other service users’ representatives. The report was available. Apart from the security issue and the flooding that was noted earlier in this report, the home was safe. The inspector checked health and safety records, such as: fire safety log, periodical electrical installations test and gas certificate. The Portable Electrical Appliances tests were outstanding. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 20 The Registered Manager must ensure that all portable appliances are tested annually by an appropriately trained person. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 21 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 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 X Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The Registered Person(s) must ensure that all individual service users’ care plans are reviewed on at least annual basis or sooner if there is a significant change. The Registered Person(s) must ensure that the premises are secure at all times. The Registered Person(s) must ensure that the mattresses in the home are checked on a regular basis and renewed when it was needed. The Registered Person(s) must ensure that the shower-heads in the home are free from limescale build-up. This requirement has been repeated. The Previous target expired on 31/10/05. 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. This requirement has been DS0000041147.V293523.R01.S.doc Timescale for action 30/06/06 2. 3. YA24 YA26 23 23 09/06/06 31/07/06 4. YA27 23 31/07/06 5. YA34 19 31/07/06 Clova House Version 5.1 Page 23 6. YA36 18 7. YA42 23 repeated. The previous target expired on 31/10/05. The Registered Person(s) must ensure that all staff receive at least six one-to-one supervision sessions in twelve months and that the records are available to evidence that. The Registered Manager must ensure that all portable appliances are tested annually by an appropriately trained person. 30/08/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA17 YA33 Good Practice Recommendations The inspector recommended that the ventilation above the cooker is reviewed. The inspector recommended that the staffing levels were reviewed in accordance with the level of supervision required by the service users. Clova House DS0000041147.V293523.R01.S.doc Version 5.1 Page 24 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 © 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.V293523.R01.S.doc Version 5.1 Page 25 - 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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