Inspection on 01/11/06 for Clova House Residential Home

This inspection was carried out on 1st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Clova House Residential Home 25/10/05

Clova House Residential Home 24/05/05

Clova House Residential Home 06/01/05

Clova House Residential Home 17/06/04

Similar services:

Snydale Care Home

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Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Clova House Residential Home 2 Clotherholme Road Ripon North Yorkshire HG4 2DA Lead Inspector Jo Bell Key Unannounced Inspection 1st November 2006 09:30 X10015.doc Version 1.40 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 Residential Home DS0000007883.V318119.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clova House Residential Home Address 2 Clotherholme Road Ripon North Yorkshire HG4 2DA 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) 01765 603678 None provided County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Mrs Jean Morton Collins McAndrew Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th October 2005 Brief Description of the Service: Clova House offers residential care to 40 people over the age of 65 years. The home is a large three storey traditional detached house standing in its own well kept and attractive grounds on the outskirts of Ripon, with the town centre and market square within reasonable walking distance. Service users’ accommodation is on all floors accessed by both shaft and stair lifts. Most service users rooms have either a pleasant garden or rural view. The scale of charges range from £346-£550 per week. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of this service took place on Wednesday 1st November 2006. Prior to the visit, information was received via the pre-inspection questionnaire and comment cards from healthcare professionals were completed and returned to the CSCI. One inspector spent six hours at the home speaking with service users, visitors and staff. The home had twenty two service users in residence and was undergoing a large refurbishment programme which is expected to be completed in the New Year. Three service users were case tracked and information relating to these individuals was examined. Health and safety issues were discussed and a sample of documentation was inspected. The quality of care in the home is good, however there are aspects of the service which need improving in order to ensure the safety of service users and the risks to them being minimised. What the service does well: What has improved since the last inspection? The home have introduced an induction booklet for staff to complete, this should further enhance the care being given to service users. Four Seasons have developed a quality assurance policy, this will be implemented in the home shortly. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 6 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 Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is good. Service users have their needs assessed in a robust manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service users files were examined, assessments are completed by either the care manager or home manager prior to admission. An initial assessment is then completed once the service user is residing at the home. This information includes details relating to social, physical, medical and psychological needs. Service users spoken with confirmed an assessment had taken place and that the next of kin had been involved. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. Service users are treated in a respectful manner and receive a good standard of care which is well documented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users spoken with all said the quality of care was good. The manager felt improvements had taken place regarding care planning, this was evident when inspecting three care plans. Detailed information was available, risk assessments for moving and handling, use of bed rails, prevention of pressure sores and nutritional assessments were all in place. The care plans clearly identified the needs of the individual service user and had reference to healthcare professionals including GP, district nurse, chiropodist and community dietician. This was also documented in the preinspection questionnaire. Service users confirmed healthcare can be accessed. There is a local hospital in Ripon with a larger hospital in Harrogate. Comment cards received from GPs were all positive regarding the care provided. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 10 Currently there are no service users with pressure sores and staff are familiar with how these are identified. The home on a weekly basis complete a risk form and send this to Four Seasons for analysis. Regulation 37 notifications are sent to the CSCI which discuss any incidents affecting service users. No serious concerns have been raised since the last inspection. Throughout the site visit staff were observed treating service users with respect and dignity, a good rapport was evident between staff, relatives and service users. Service users looked clean and well cared for and this was confirmed when speaking with service users. The medication system was checked. Medication was found to be stored correctly both in the drug trolley and fridge. The home have a medication procedure in place and staff have attended medication training. Medication charts were checked and whilst there were no omissions it was apparent on one occasion that the stock balance recorded of Prednisolone did not tally with the amount stored in the medication box. Eighteen tablets could not be accounted for. Following discussions with the manager and pharmacy it was deemed to be an error in the counting of the tablets when they were first received. Staff must ensure they check and record correctly the amount received. One service user who was spoken with in the lounge had next to her a medicine pot with orange liquid in, the person did not know what this was or whether it should be drunk. In discussions later with the deputy manager it was evident that this was the service users pain relief which had been signed for but not administered. This person was confused and should have been observed taking this medication. The controlled drugs book was checked, when a controlled drug is given generally two care staff sign the book. However, the home manager is also a registered nurse and felt when she is administering controlled drugs only one signature is needed. This needs to be clarified with Four Seasons as this is not stipulated in the medication procedure. On other occasions for example if a syringe driver needs setting up the manager would contact the district nurse, and therefore not act as a registered nurse. Whilst this does not necessarily affect the outcome for the service user, it does have accountability issues for the home manager. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. Service users can participate in a range of activities and are encouraged to be autonomous, the meals are adequate however more choice is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users can participate in activities, which are delegated to a carer each day. The home is currently recruiting for an activities organiser which will bring more focus to the activities. Service users confirmed that they go out for walks, play bingo, have Ripon Grammar School students come to visit and have access to the local church when needed. Some service users like to sit outside as the views are wonderful across the fields. Visitors are welcome at any time, one visitor confirmed tea and coffee are offered and staff are always friendly when they arrive. The visitors book confirmed a range of people come to visit at different times. Service users confirmed that they are able to get up and go to bed when they want. They can choose when they receive personal care and where they eat their meals. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 12 The meals provided were discussed and sample menus were included in the pre-inspection questionnaire. Service users are not given a choice at lunchtime regarding main courses, staff inform them what is for lunch and if the service user does not like the food they are given an alternative. At tea- time a choice is offered. Lunchtime was observed and in one communal area five service users were sat at a dining table and two in lounge chairs. The television was on quite loud in the background, though service users were not watching this. Plates, cutlery and napkins were provided with artificial flowers arranged on the table. The meal was ham and vegetables, normally there is one frozen vegetable and one fresh. Four out of the seven service users ate all their main course with the other three leaving approximately half. No alternative was offered, the food was taken away and the milk pudding dessert was brought, this was clearly enjoyed by all the service users observed. A review of the menus would be beneficial to ensure there is sufficient choice and variety for service users. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Service users feel safe and are confident their concerns will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have a complaint procedure in place. No formal concerns or complaints had been received either by the home or through the CSCI. Service users spoken with confirmed they were happy to discuss any issues with the person in charge and felt these would be dealt with appropriately. Adult protection was discussed. Four Seasons have a policy in place which highlights the procedure to follow. There is also a designated ‘Whistle Blowing’ helpline available for all staff. Two care staff were spoken to regarding caring for vulnerable adults they were both aware of the different types of abuse and the action to take if an incident occurs. Training has previously taken place in this area which has been beneficial. A discussion took place with the manager regarding the action to take if an incident is reported to her. The manager was aware that Four Seasons, the Police and CSCI need to be informed. However, the person in charge needs to be aware that Social Services take the lead and an adult protection referral would need to be made to them. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 26 (Standard 19 will be assessed following completion of the refurbishment work) Quality in this outcome area is adequate. Service users live in a pleasant environment, though staff have not been updated on infection control procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As the environment is in the process of a refurbishment it was felt appropriate to assess this area when the work is completed, though health and safety aspects were examined. It was evident in one service user’s room that access to the call bell system was not given. This must be addressed. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 15 The laundry room was examined and whilst this was down some stairs, and in the basement of the building, the member of staff stated she was happy working in this environment and this did not affect the outcome for service users. Staff were spoken with and they confirmed they have not received infection control training, this needs to be addressed. Both sluice rooms were examined and whilst these were clean and tidy neither of them had a lock on and the water temperatures were above the normal range (reading taken 31/10/06 49 degrees centigrade). Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. Service users are cared for by staff in suitable numbers who are competent at their job, though improvements to the recruitment procedure are needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the site visit there were twenty two service users residing at the home. There were sufficient staff to meet the needs of the individuals. During the morning four staff were available and overnight there are two care staff. The manager is supernumerary and has a deputy to support her who currently works on the floor. The home have a key worker system in place and whilst this needs further amendments to become person centred care service users spoken with confirmed this system was in place and were happy with the staff group. The home have had a high turnover of staff in previous months, this is partly due to staff been employed from the army barracks and also because staff were unsure whether a refurbishment was taking place which affected staff morale. Staff spoken to confirmed they had undertaken some training and the NVQ Level 2 is offered, though currently only 25 of the staff have undertaken and completed this. Four seasons need to address this as there were some staff who had been waiting to start this training who were keen and enthusiastic to develop their skills and move forward. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 17 Recruitment practices generally were good, the manager was aware of obtaining two references and CRB/POVA checks prior to commencement of employment. Three staff files were checked, one of which had two references, one had a reference from a previous employer and a character reference and the third did not have any references though the manager gave assurances these had been obtained. These files need to be checked and maintained in a satisfactory manner. Staff receive induction training and Four Seasons have developed a new pack which was available for use. This was extremely in-depth and contained information relating to privacy and dignity, care practices and the skills needed to work as a carer. This will include mandatory training for all new staff when fully implemented. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. The home is generally run in the best interests of the service user though improvements to the health and safety system in the home need to be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has completed an NVQ Level 4 in Management and is a registered nurse with many years experience of caring. Staff commented positively on her friendly and professional approach this was evident throughout the visit. The home confirmed that Four Seasons have developed a quality assurance system and this is being introduced into all the homes. At present staff discuss any concerns with service users on an informal basis. Staff meetings take place though no residents/relatives meetings have Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 19 occurred. This should be reviewed. Auditing in some areas takes place i.e. accidents/risks/pressure sores though this needs to be more robust. Service user’s fiancés were discussed, currently the home has power of attorney for three service users. Individual bank account details are available and there is a pocket money fund with recorded balances for each service user. These were checked and found to be accurate. Health and safety in the home was checked, information was also available in the pre-inspection questionnaire. Certificates for gas safety, emergency lighting, lifts and hoists and fire alarm testing was available. Water temperatures had been checked on 31st October 2006 and these were found to be variable. Two sluice temperatures were recorded at 49 degrees centigrade and those checked in service users’ room again varied from within the expected parameters to slightly high. These need to be adjusted. The manager confirmed that fire drills take place once or twice a year and staff receive training in this area twice a year. Currently the home has not had a fire risk assessment and there are approximately five service users who do not have fire sensors in their rooms. These issues must be addressed to ensure the safety of residents and staff. Mandatory training was discussed, some staff confirmed they had received fire training and moving and handling though they were unsure regarding COSHH training. Staff training records were checked and these suggested moving and handling, infection control, and COSHH had not been undertaken in the last twelve months. The manager must ensure training is completed and recorded correctly. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 N/A x x 1 x x x 1 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 1 Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP15 OP9 Regulation 12 13 Requirement A review of the choice of food available must take place. A monthly medication audit must take place. Staff must only sign for medication once it has been administered. Staff must ensure the stock balances for medication are checked correctly. Each service user must have access to a call bell in his/her room at all times The sluice rooms must be kept locked when not in use. Staff must receive infection control training. Two written references must be available in the staff files as evidence that the references have been obtained prior to employment. Staff must receive mandatory training, which must be documented and kept up to date. The home must confirm in writing to the CSCI that the high water temperatures have been adjusted. DS0000007883.V318119.R01.S.doc Timescale for action 01/12/06 01/12/06 3. 4. OP22 OP26 23 13 01/11/06 01/12/06 5. OP29 19 01/12/06 6. 7. OP38 OP38 13 13 01/12/06 10/11/06 Clova House Residential Home Version 5.2 Page 22 8. OP38 23 A fire risk assessment of the home must take place. Service users rooms must have sensors put in place to minimise the risk of harm from a fire. 01/12/06 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 OP28 OP33 Good Practice Recommendations 50 of care staff should be trained to NVQ level 2 or equivalent. Implementation of Four Season’s quality assurance system needs to take place. Clova House Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Residential Home DS0000007883.V318119.R01.S.doc Version 5.2 Page 24 - 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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