CARE HOMES FOR OLDER PEOPLE
Clova House Residential Home 2 Clotherholme Road Ripon North Yorkshire HG4 2DA Lead Inspector
Mrs Irene Ward Unannounced Inspection 25th October 2005 09:45 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.V259847.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 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.V259847.R01.S.doc Version 5.0 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 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), Physical disability (1) of places Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The category (PD) applies to a named service user for respite care only 24th May 2005 Date of last inspection 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 DS0000007883.V259847.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 17th October 2005, which started at 9.45hrs and finished at 15.45 hrs. A tour of the home was carried out which included the service users’ private accommodation, a selection of records were looked at and time was spent observing activity in the home, talking and listening to service users, relatives and staff. The focus of the inspection was a number of key standards, inspecting the care records of five service users in detail to establish if they corresponded with service users experiences in the home. There were also discussions with the registered manager of the home. What the service does well: What has improved since the last inspection?
All of the requirements made at the last inspection apart from one have been implemented. Staff training is comprehensive and available to all staff. The homes manager has organised relevant courses involving other health care professionals such as the Community Dietician to undertake training regarding nutrition for older people. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 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 DS0000007883.V259847.R01.S.doc Version 5.0 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.V259847.R01.S.doc Version 5.0 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 the following standard(s): 2,3,5 and 6 Prospective service users can be confident before moving into the home that their needs can be met. EVIDENCE: A pre-admission assessment is carried out and an assessment form is completed prior to admission into the home. A care plan from a placing or funding authority where applicable is also obtained. The information on files was comprehensive and details give good indication of the care needs of service users. Service users and their relatives are encouraged to visit the home prior to admission. Service users can stay for the day or have an overnight stay at the home. All service users or their representatives are to be issued with the organisations Terms and Conditions, which have been updated. The registered manager stated that the home does not provide intermediate care.
Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The health care needs of service users are well met. EVIDENCE: Five service users’ case files were inspected, which contained comprehensive plans of care. Risk assessments covering areas of daily living were available and up to date. The health care needs of service users were recorded on their individual care plans that had been regularly reviewed. For those service users that are unable to self medicate the home operates a monitored dosage system, which was inspected. Medication was appropriately stored and records were accurately maintained. There were three service users being cared for in bed. One service user is bed bound, whilst the others are encouraged and supported to sit out. There was no evidence in their care plans or in the discussions held with the manager to suggest that the service users at this moment in time are requiring nursing intervention, as the home is meeting all of their care needs. The home’s manager is aware of her responsibilities if service users’ conditions change and
Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 10 require regular nursing intervention. None of the service users had pressure sores. One visitor to the home stated that the home is very good and staff are always helpful. However a number of service users stated that overall staff are very good “always polite, but some can be sharp”. This was fed back to the home’s manager who agreed to investigate this matter and to report back to the Commission. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 and 15 Service users’ lifestyles within the home reflects their wishes and service users are encouraged by the staff team to continue with their individual interests EVIDENCE: Visiting arrangements are flexible throughout the day as this was confirmed by the comments made by service users and one visitor. There are regular activities most afternoons such as a game of snakes and ladders being played by a number of service users in the afternoon,whilst some service users had been out to a coffee morning and various entertainers are available. Mealtimes at Clova are flexible. All service users spoken with commented that the food at the home was very good. Menus had been displayed on the notice board but had kept disappearing. The manager was advised to look towards an alternative way of informing people such as a chalkboard. Menus are on a four weekly roster. In discussions held with the cook special diets are catered for. Service users are assisted with feeding where necessary. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16, 17 and 18 Service users are confident that their complaints and concerns are dealt with and are acted upon. EVIDENCE: The home’s complaints procedure is available to service users and visitors as it is on display in the main entrance to the home. Service users commented that if they had a complaint or a concern that they would speak directly with the manager. There are adequate policies and procedures in place to deal with complaints. There have been no complaints received by the Commission. The home’s adult protection policies and procedures are in place. 80 of the staff team have undertaken training in this area. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19,20,21,23 and 26 Service users’ rooms are maintained well but communal areas are “shabby” and unwelcoming. EVIDENCE: The main entrance into the home requires re-decoration, which was made a requirement at the last inspection. This has not yet been completed. Which makes the main entrance into the home appear shabby and unwelcoming. The organisation should give priority to the re-decoration of this area. The home overall was clean and free from odours except for two areas. One of which was in the main entrance hall and one bedroom. This was discussed with the manager who stated that this would be addressed. Service users rooms have been personalised making them as homely as possible with their own possessions. The home has four bathrooms on the ground floor and 2 on the first floor. There is a passenger lift and stair lift available.
Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 30 Service users receive a good standard of care from staff that are competent and trained. EVIDENCE: The staff rota showed that there are four care staff on each morning and afternoon. There is two care staff on duty each night. There is a separate rota in place for all ancillary staff. Staff training is ongoing with staff attending all the statutory training as required. Staff have had access to various training such as Safe Handling of Medication, Dementia Awareness, Infection Control and so on. The home’s registerd manager is completing training in the Management of Aggression. There are 6 staff that have completed NVQ Level 2 and above. 2 staff are to commence NVQ Level 2. However the home does not yet meet the 50 ratio. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,37 and 38 Service users’ health, safety and welfare are generally promoted and protected with one exception regarding fire precaution. EVIDENCE: Service users finances were inspected. The home operates the organisations procedures, which were being followed. Service users’ individual monies could not be inspected to ascertain they balanced as monies are held together in one account although individual records for all service users’ finances are maintained. Receipts are obtained for all purchases and two signatures are also obtained for all monies received and withdrawn. Regular audits are carried out by the organisation’s Regional Support Administrator. A number of health and safety records were inspected all of which were up to date and accurately maintained. However several fire doors were wedged open
Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 16 by unauthorised means. An immediate requirement was issued to remove wedges from any fire doors. Advice was given for the home’s manager to seek advice regarding the installation of appropriate systems from the Fire Safety Officer. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 17 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 3 X 3 X X 1 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 3 1 Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 18 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. 2. Standard OP10 OP19 Regulation 12(2) 23 Requirement The registered person must ensure that service users are treated with respect at all times The registered person must ensure that the entrance hall on the ground floor must be redecorated. The main hallway and bedroom 29 had an offensive odour. These areas must be cleaned and free of any odours. Fire doors must not be wedged open. Timescale for action 25/10/05 31/12/05 3. OP26 16(2) (k) 03/11/05 4. OP38 23 (4) (i) 25/10/05 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. Refer to Standard OP28 Good Practice Recommendations 50 of care staff should be trained to NVQ level 2 or equivalent by the end of 2005. Clova House Residential Home DS0000007883.V259847.R01.S.doc Version 5.0 Page 19 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
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