Inspection on 24/05/05 for Clova House Residential Home

This inspection was carried out on 24th May 2005.

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 01/11/06

Clova House Residential Home 25/10/05

Clova House Residential Home 06/01/05

Clova House Residential Home 17/06/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 David White Unannounced 24 May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 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 N/A N/A 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 J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 06/01/05 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. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection that took place on Tuesday 24th May 2005. It was undertaken over 8 hours. The focus was on a number of key standards together with those subject to requirements or recommendations at the last inspection. The inspection included a look around the premises. The care records of five residents were examined in detail and four of these residents were spoken with about the care they receive. A discussion was also held with a visitor to the home. A number of records in relation to the running were inspected. Discussions were held with the registered manager and a relief cook. What the service does well: What has improved since the last inspection? The ongoing refurbishment programme has meant that a further number of bedrooms have been redecorated and look more welcoming and homely. Residents, prospective residents and visitors have more detailed information about the home following the amendments to the Statement of Purpose. Recruitment procedures are more robust to safeguard residents from harm. The driveway has been repaired so reducing the risk of harm to residents, staff and visitors to the home. A questionnaire has been introduced to promote residents and visitors to voice their views about the home. The improvement in the care planning documentation promotes all aspects of resident healthcare. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6 People are provided with relevant information about the home and together with the admission procedure assures residents and prospective residents that their care needs will be met. EVIDENCE: The new revised and updated Statement of Purpose provides relevant information about the home. Prospective residents and their families receive a brochure, which provides general information about Clova House. At the time of inspection a relative was making an enquiry about the suitability of the home for a prospective resident and the registered manager was sending out the home’s brochure along with a copy of the Statement of Purpose so that the relative had a range of information to be able to make a decision about the home. The relative had also been invited to look around the home with the prospective resident. The assessment documentation of five residents was of good quality and provided sufficient detail for informative care plans to be developed. Preadmission assessments are carried out either by the registered manager, the deputy manager or the Head of Care, all of whom are appropriately qualified to do so. Pre-admission assessment forms were supported by an assessment and Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 9 initial care plan from the placing or funding authority where applicable. At the time of inspection the manager was visiting one of the residents’ who had been admitted into hospital to re-assess their needs. The residents spoken to were able to confirm the documented details in relation to their personal assessments and felt that the relevant information about their physical, mental and social needs was accurate. The registered manager stated that intermediate care is not offered in the home. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 and 11. Healthcare needs of residents are generally well met although there was one exception to this, which potentially placed a resident at risk. There is an issue of protecting dignity whilst providing personal cares. EVIDENCE: Progress has been made in improving the quality of the care plans. Individual care plans were available for all five residents spoken with. The plans covered all aspects of health and personal care and this included a detailed social assessment for each resident. Each individual file contained a range of risk assessments covering a number of aspects of daily living. Care plans are regularly reviewed on a monthly basis. The health care needs of residents were recorded within their individual files. Referrals to outside health agencies were detailed. Nutritional assessments were in place in the files inspected and weight is monitored on a regular basis. None of the residents had pressure sores. One resident being cared for in bed had a pressure-relieving mattress that had been supplied by the District Nurse. Most residents commented positively about the care they received. A resident described the care as “good, all my needs are met”, another said “overall the care is pretty good” and a visitor commented that the care in the home generally was “impressive”. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 11 One resident spoken with has diabetes and commented that he used to monitor his own blood sugar levels but said that this was no longer being done by anyone. The care plan relating to this resident stated that following a care plan review it had been decided that the care staff would be responsible for the daily testing of the resident’s blood sugar levels, however the records showed that this was not being done. Most residents with one exception felt that staff support with their health and personal cares was provided in a respectful manner. One resident needed assistance on an evening to get ready for bed. He commented that on some occasions the night staff had been called away whilst still assisting him leaving him in situations, which he felt “showed a lack of respect for my dignity”, and which left him feeling “embarrassed”. Residents have access to a personal telephone so they can have conversations in private if they choose. Staff were observed to be respectful when addressing residents and knocked on bedroom doors before entering. The individual care plans contained information relating to resident’s wishes concerning arrangements following death where this was felt appropriate. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, and 15. Flexible visiting arrangements enable residents to maintain good and regular contact with their family and friends. The dietary needs of the residents are met. EVIDENCE: Residents confirmed that they could have as many visitors as they liked and at any time they chose. One visitor spoken with said, “staff were always “welcoming” and “helpful”. Residents commented that the maintenance of regular contact with their families and friends was a very important aspect of their care. The registered manager has developed a nicely presented newsletter which will be available to residents and visitors and which includes information about forthcoming activities. Those residents spoken with gave mixed views about the range of meals offered in the home. One resident said the meals were “very good”, whilst another commented that the quality of the food was “nice”. However three residents said that the food provided on an evening was “basic” and offered little variation. A number of residents were also unaware of what they would be having for their meals and menu choices were not on display in the home. The relief cook was spoken with and demonstrated a good understanding of the dietary needs of the residents. Specialist diets are catered for and were presented in an attractive manner. Residents are given assistance with feeding where appropriate. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints are dealt with appropriately to safeguard resident’s interests. EVIDENCE: There are adequate policies and procedures in place to deal with complaints and information about the complaints procedure is on display in the home. There have been no complaints since the previous inspection. Residents said they were aware of how to raise any concerns. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22, 24, 25 and 26. Recent investment has improved the appearance of the home but further investment is required to ensure that the home is safer and more pleasant for residents to live in. EVIDENCE: The home is continuing with their refurbishment programme. Re-decoration work to ten bedrooms has vastly improved the living environment within these areas. As bedrooms become vacant continuing re-decoration work will be carried out. The conservatory has also been updated and there is now new flooring and blinds on the windows to maintain privacy. Further refurbishment work is required in the conservatory that will include the replacement of the existing furniture. Newly installed wall mounted heaters have been installed in the conservatory and a risk assessment needs to be carried out in relation to this. Necessary repairs to the driveway of the home have been completed although further work is required and the registered manager has arranged for this to be carried out. One of the boilers had broken down and was due to be repaired. The lack of the boiler did not have any significant impact on the care being provided. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 15 The home has a passenger lift and a stair lift and access was available to all external doors. Various aids and equipment were in place to meet resident needs. It is recommended that a suitably qualified person inspect the home’s premises and facilities to ensure they are meeting the needs of the residents. Some areas are in need of attention. The carpet in bedroom 2 is very worn and the entrance area to the ground floor is in need of re-decoration. The bathroom on the ground floor was cluttered by the storage of two wheelchairs in this area. The wheelchairs were obstructing the pathway to the toilet and making access difficult for residents. An immediate requirement was issued in relation to this matter. The home was clean and tidy and free from offensive odours. Personalised resident bedrooms were clean and residents spoken with confirmed that their bedroom is cleaned and maintained on a regular basis. There are two sluicing facilities in the home one with a disinfector. Appropriate in-house arrangements are in place for the laundering of bedding, linen and personal clothing. The last reports from the Fire Officer and Environmental Health Officer were examined and any outstanding issues have been addressed. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29. Residents are cared for by a committed staff team, however the deployment of staff available does not ensure that resident needs are fully met. EVIDENCE: The home currently has vacancies for catering, domestic and cleaning staff. The registered manager has received applications for all these posts and is hoping to recruit shortly once all the pre-employment checks have been returned as satisfactory. The file of a recently employed member of staff was checked and all the necessary checks had been carried out to protect the residents. Duty rotas showed that staffing levels meet the requirements. Staff were observed to be hard working and under pressure. Residents spoken with described the staff as “polite, caring and friendly” but said that they were very busy and sometimes it took a long time for them to answer call bells particularly in the morning and at nighttime. A visitor to the home reported the same concerns. One resident said that on occasions in an evening the night staff had been called away whilst still assisting him to get ready for bed leaving him unattended to until they returned from their other tasks. This was having an upsetting impact on the resident. Another resident commented, “staff seem too busy to be able to sit down and talk to you”. The home is currently without a permanent cook. A cook from another home is helping out for two days a week. A relief cook is also used to cover some shifts. There is also a vacancy for a cleaning post at the home. The arrangements for catering and cleaning don’t appear to be having a detrimental effect on the home although the employment of a permanent cook Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 17 and additional cleaner should improve these services and provide more consistency for residents. 33 of the care staff are now trained to NVQ level 2. Five members of staff are undergoing NVQ level 3 training and one member of staff is due to commence the NVQ level 2 course. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The manager is supported by the senior staff in providing leadership throughout the home. The health and safety practices in general safeguard residents from harm although there was one exception to this. EVIDENCE: The registered manager is well experienced in running the home and has a good understanding of the individual needs of the residents. She is a qualified nurse with a certificate in management and health. Residents and the visitor spoke in complimentary terms about the manager’s abilities. All said she was “approachable and adopted a hands on approach” and would feel comfortable in raising any concerns with her. One resident said the registered manager had a “very good attitude”. The registered manager has developed a questionnaire since the previous inspection that was intended to seek the views of residents and visitors about the care and services provided in the home. However the response to the questionnaire had been poor. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 19 A number of satisfactory safety reports and certificates were seen relating to the premises. It is recommended that the handyman record what measures have been taken when hot water temperature checks exceed the required safety levels. A random hot water temperature check in a first floor bathroom was found to be satisfactory. A fire door on the first floor was wedged open. An immediate requirement was issued to remove the wedge from the fire door. Records indicated that fire drills and instruction had taken place regularly. All other fire safety records were up to date. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 x 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 1 x x 2 x 3 1 3 STAFFING Standard No Score 27 1 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x 1 Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 21 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. Standard 8 Regulation 12 Requirement The registered person must ensure that actions required to met the assessed needs of a resident with diabetes are being undertaken. The registered person must ensure that at all times the home is conducted in a manner which respects the dignity of the residents. The worn carpeting in bedroom 2 must be repaired or replaced. The entrance area to the ground floor must be re-decorated. Wheelchairs causing obstruction to the ground floor bathroom are removed so that residents are not placed at risk from tripping or falling. A risk assessment must be undertaken in relation to the newly installed wall mounted heaters in the conservatory. Staffing arrangements shall be reviewed for early morning and nightime to ensure that all the needs of the residents are met. Fire doors must be able to close freely in the event of the alarm sounding J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Timescale for action As from 24/05/05 and thereafter. As from 24/05/05 and thereafter. 31/08/05 31/08/05 Immediate as from 24/05/05 and thereafter 31/05/05 2. 10 12 3. 4. 5. 19 19 19 23 23 13 6. 25 23 7. 27 18 30/07/05. 8. 38 13 Immediate as from 24/05/05 and Page 22 Clova House Residential Home Version 1.30 thereafter. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 15 22 28 38 Good Practice Recommendations The menu choice on an evening is reviewed and menu options should be on display in the home or read to the residents. A suitably qualified person makes an assessment of the premises and facilities. 50 of care staff should be trained to NVQ level 2 or equivalent by the end of 2005. The handyman should record what measures have been taken when hot water temperature checks exceed safe levels. Clova House Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO32 9GZ 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 Residential Home J53_J04_S7883_Clova House_V226710_240505_Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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