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Inspection on 10/06/05 for Clovelly House

Also see our care home review for Clovelly House for more information

This inspection was carried out on 10th June 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The current proprietors` mother originally established the home, to provide a `home from home` service, and Clovelly House remains very family orientated, and service users feel it is their home. As the needs of service users living in the home change, additional equipment is provided therefore ensuring that the service users are able to remain living in the home.

What has improved since the last inspection?

Since the last inspection, the front of the home has been repainted, and the range of activities available to service users living in the home has been increased. Work has also been done in the kitchen, tiling the complete area in accordance with environmental health recommendations. One of the staff members has now taken on the role of activity co-ordinator, and is helped in this by her husband, and a number of trips have been arranged or are planned. The new manager is ensuring that regular maintenance is done on equipment, and new equipment purchased where required.

What the care home could do better:

The manager was happy with the way the service operates, and has already made some worthwhile changes. As she develops into this role further, other changes will undoubtedly happen, maintaining the service and progress that the home has always been noted for. The new manager should to be more confident in her own abilities, but this will come with experience and the further training she is undertaking.

CARE HOMES FOR OLDER PEOPLE Clovelly House 44 Station Road March Cambridgeshire PE15 8LE Lead Inspector Alan Buttery Unannounced 10 June 2005 @ 12:00 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. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clovelly House Address 44, Station Road March, Cambridgeshire, PE15 8LE. 01354 655768 01354 661806 clovellycare@aol.com Mr Malcolm George 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) Mrs Angela Grant Care Home 21 Category(ies) of DE(E) 21 registration, with number OP 21 of places Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14th February 2005. Brief Description of the Service: Clovelly House provides residential care for older people, and those with dementia in the Cambridgeshire town of March. The premises are in an Edwardian House, which has been extensively modernised and extended to meet the needs of the service users living there. It is close to the town centre and within easy reach of local facilities.The same family has operated the home for a number of years, although changes in the management structure have recently taken place following the death last year of the registered provider. The business is now solely owned by the previous providers son, Mr Malcolm George, who was previously registered manager. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, and the first of the current inspection year. The inspection lasted about 2 hours, and looked at specific standards. Arrangements were made for the inspector to attend a Service user meeting later in the year, at which point, the more detailed views of service users will be gathered. The home is currently full, with a waiting list, and there are no vacancies for staff, and there have been no changes in staff since the last inspection. The homes current fees range between £330 and £420, and service users contribute toward the cost of trips and outings, and pay for their own hairdressing, chiropody, and personal toiletries. Comment cards were left for service users and families to complete, and any views expressed will be incorporated in the next inspection report. What the service does well: The current proprietors’ mother originally established the home, to provide a ‘home from home’ service, and Clovelly House remains very family orientated, and service users feel it is their home. As the needs of service users living in the home change, additional equipment is provided therefore ensuring that the service users are able to remain living in the home. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - 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 Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - 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) 3 Clovelly House has a detailed admission procedure, including visits from service users, ensuring that the needs of service users moving into the home can be met EVIDENCE: During the inspection, the files for two service users who have recently moved into the home were examined, and included pre admission assessments, risk assessments, moving and handling information, and details of the likes and dislikes of service users. The files also contained copies of the complaints policy, which has incorrect contact information for the CSCI, but is currently being revised along with all the homes other policies and procedures. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 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 standard(s) 7, 8, and 10 Care plans used by the home provide staff with sufficient information to meet the health needs of service users, in a dignified and respectful manner. EVIDENCE: All service users have individual care plans which provide staff with the information they require to deliver care, but discussions with the manager and deputy manager identified some improvements that could be made to these care plans and these will be implemented by the manager. The staff team meets Service users health care needs, with assistance from visiting health professionals, and the home has a very good relationship with the local GP’s. The homes quality assurance survey includes questionnaires for health professionals. Service users spoken to, and the questionnaires they complete confirm that staff treat them with dignity and respect at all times, Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 10 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) 12, 13,14 and 15. A range of activities both within the home and in the local community are arranged, which include families, and provide service users with a varied programme to choose from. EVIDENCE: The level and nature of activities available in the home has increased, and one of the staff members now takes on the role of activity co-ordinator, assisted by her husband. A range of trips have been arranged or are planned, including visits to Sandringham House and Gardens, local garden centres, Band concerts in the town and various other events. They are also arranging a garden party next month, which relatives will be invited to, and hope to have ‘summer teas’ on a regular basis to make use of the garden. Visitors are encouraged at any time to visit relatives, and join in trips and activities. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 11 Regular visits from local clergy are encouraged, and services arranged in the home. Any service users wishing to attend the local church in person would be supported to do so wherever possible Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 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 standard(s) 16 A complaints procedure is in place to manage complaints appropriately, although this needs to be updated. EVIDENCE: The home has a complaints policy, but as indicated above this is currently being revised, and the contact information for the CSCI must be updated, to ensure service users and their families are able to make contact with the commission should they wish to. There have been no complaints made either to the home or to the CSCI since the last inspection. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 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 standard(s) 19 and 26 The home continues to offer service users a comfortable and safe environment to live in, with their own possessions around them if they choose. EVIDENCE: The home provides a safe and well-maintained home for the service users living there, and regular maintenance is done to keep the home in good order. They are currently planning to install a small stair lift to the upper landing on the first floor, which will enable service users with mobility difficulties to safely access the remaining six bedrooms. The rear lounge is scheduled for redecoration later in the year, but in general the home is decorated to a high standard. The home was free from offensive odours, and on the day of the inspection clean and tidy. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 14 Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 15 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 and 30 The procedures for the recruitment of staff are robust and offer protection to people living in the home. The deployment and number of staff available is appropriate to meet the needs of the service users. EVIDENCE: There have been no changes to the staff team since the last inspection, and the home has suitable numbers of staff working at all times to meet he needs of the service users living there. Staff are provided with the training necessary to carry out their duties, and the manager is currently looking at ways to provide training in a more interesting format. The manager herself is currently taking her registered managers award, and has been able to introduce some of the ideas she has learned to the home. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 16 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, 33, and 38, The home is well managed and staff receive leadership, guidance and direction to ensure service users receive consistent quality care. The health, safety and welfare of the people using the service is promoted and safeguarded at all times. EVIDENCE: The homes new manager has already introduced some new ideas, some of which she has learned from her Registered managers award, and although still slightly unsure of her own abilities, is well respected by the staff in the home, and has a particularly strong relationship with the service users. The homes owner is usually available to offer support, but confident in her abilities to manage the home. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 17 It is clear that service users interests are firmly at the forefront of anything happening in the home, and if new equipment is required to maintain their stay in the home, this is provided. All the required health and safety procedures and training are in place, and regular checks of the alarm systems, boilers, and water temperatures are carried out Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 18 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x 3 x x 3 x x Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 16 Regulation 22(7) Requirement The homes complaints procedure must contain contact details for the CSCI Timescale for action 31/08/05 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 7 Good Practice Recommendations The homes care plans should be revised to clearly show the care planning and review process. Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 20 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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 Clovelly House I53 I03 S15292 CLOVELLY HOUSE V231230 100605 - STAGE 4.doc Version 1.30 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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