Inspection on 10/05/05 for Clovelly House

This inspection was carried out on 10th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clovelly House 18/07/06

Clovelly House 08/11/05

Clovelly House 09/11/04

Clovelly House 29/06/04

Clovelly House 09/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Clovelly House 18 St Michaels Road Newquay Cornwall TR7 1RA Lead Inspector Alan Pitts Announced 10 May 2005 10:00 a.m. 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 D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clovely House Address 18 St Michaels Road, Newquay, TR7 1RA 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) 01637 876668 01637 879958 Mrs June Anastasia Hartigan Mrs June Anastasia Hartigan Care Home 19 Category(ies) of Old age registration, with number of places Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Total number of service users not to exceed 19 Date of last inspection 9th November 2004 Brief Description of the Service: Clovelly House is a registered care home which offers accommodation and personal care for to up to 19 older people. It is located close to the centre of the town of Newquay. The home is situated with easy access to shops, transport and all the amenities of a small town. It is sited in its own grounds, slightly off the road, with ample parking.The home is located across two floors. The upper floor is accessible by lift. All the bedrooms are occupied as single rooms and most of them have en suite bathroom facilities. All are provided with sink units. In addition there is a spacious lounge/dining room, a quiet room and two conservatories. Several of the rooms have views across the town and to the sea beyond.The Registered Provider lives near to the home and manages the home on a day-to-day basis, with the support of the family. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Clovelly House provides a comfortable home with a relaxed family atmosphere, and the evident contentment of the service users impressed the inspector. The Registered Providers must give priority to the requirements and recommendations identified in this report, which are of a managerial nature. Service users were evidently well cared for and expressed only positive comments about the home and the staff. What the service does well: What has improved since the last inspection? The Registered Provider has made clear efforts to improve the documentation kept within the home, and demonstrated a positive attitude to the improvements still to be made. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.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. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.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 D52-D04 S8944 Clovely House V214848 100505 Stage 1.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, 2, 3, 4, 6 The inspector has no doubt that the current service users are well informed, but the Registered Providers need to formalise the manner in which information is available and provided to service users and potential service users. EVIDENCE: The combined Statement of Purpose and Service Users Guide includes the information listed in Schedule 1 of the Care Homes Regulations. The Registered Provider has worked on this document since the last inspection and needs only to elaborate on the information provided. This combined document should also include a copy of the most recent Inspection report and the Registered Provider has undertaken to ensure that Service Users views are included. A copy of the information is made available in the lounge. The Service Users Guide must be made available to all prospective Service Users. All new service users have signed a contract that includes their terms and conditions with the home. Social Services Department contracts are now provided in respect of all service users placed at the home by local authorities. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 9 The Statement of Terms and Conditions would benefit from a more detailed breakdown of fees, how they are paid, and by whom. All Service Users admitted to the home are fully assessed by the Provider who is a qualified nurse or by an experienced member of staff. A Pre-assessment document has been compiled for the home. Service Users and their relatives are encouraged to visit the home before making a decision whether they wish to move in. The Registered Provider was able to demonstrate a good understanding of the service user’s care needs and capabilities. National Minimum Standard 6 is not applicable as this service is not provided at this home. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.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, 9, 11 The Registered Provider has an in-depth knowledge of service user care needs, but this should be better evidenced in care plans. EVIDENCE: All Service Users have a care plan but this does not currently cover all aspects of personal, social and health care needs. The Inspector and Registered Provider discussed the documentation, and the need for the care plan to direct care. The care plans should identify the care need, the aim of intervention and the actual intervention to be carried out. The care plan should be THE document that informs carers and should be reflected in the carer’s written entries in the daily records. The Registered Provider should ensure that there are two staff initials when it is necessary to transcribe prescribed medication to a Medication Administration Record. The medication policy in operation should be reviewed and expanded to include the ordering, receipt, storage, administration, disposal and return of medication. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 11 It is unacceptable to prepare syringes in advance. It is only acceptable if syringes are labeled in accordance with the Medicines Act 1968, i.e. full labeling requirements. This issue was previously brought up with the Primary Care Trust (PCT). The Commission for Social Care Inspection pharmacist has spoken to the Central PCT with regards to this matter and has arranged a meeting with regards to the above. The Specialist Diabetic Nurse at Central PCT has also previously agreed with this is unsafe practice, only acceptable in urgent one off/difficult situations. Service user wishes in respect of dying and death are recorded in the admission documentation, but this was blank in a number of records. The Registered Provider should ensure that this information is acquired as part of the pre-admission or admission process. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.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) 12, 15 The Registered Provider and care staff are evidently committed to service user comfort and quality of life. Service users were positive about all aspects of life at Clovelly House. EVIDENCE: A monthly activity planner was evident. Two cars are available as transport for service users, and a local minibus is used on occasion. The care documentation shows evidence of service user participation in social and recreational activities. Service user comments were positive about all aspects of daily life at the home. A 3-week menu is in operation. The Registered Provider and service users confirmed that a choice is always available. There are two hot meals available every day. Service users are not currently asked if they would like an alternative meal at the lunchtime meal, the Registered Provider saying that service users would ask if they so wished. This was discussed and the Registered Provider undertook to ensure that service users are asked every morning if they would prefer an alternative to the planned lunchtime meal. Service users stated that the food provided was of a high standard and in plentiful amounts. Service users confirmed that food would be available to them at any time. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 13 Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 14 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, 17, 18 The Registered Providers are aware of adult protection issues, but need only to provide a procedure, which would give staff clear instruction and contact details. Service users spoken with were complimentary about the kindness and consideration shown by staff. EVIDENCE: The home has a written complaints Procedure, which includes the required information. All the service users spoken to said that they are well cared for and were aware of whom to speak to if they were unhappy about anything. No complaints have been made in the last twelve months. The Commission for Social Care Inspection has received no complaints in respect of this home. Service users spoken with confirmed that they had the right to vote if they so wished, and that they received their mail unopened. The home has a policy in relation to the Protection of Vulnerable Adults that provides definitions of what abuse is and information is available on the DOH No Secrets publication. There is a Whistle blowing Policy. Training has or is being provided for all staff. The service users spoken to at the time of the inspection stated that they feel safe in the home, they are well cared for and staff treat them well. The Inspector observed staff to treat service users with kindness and respect at all times. The Registered Provider should review and expand the existing protection of vulnerable adults policy to ensure that it provides clear instruction to staff and Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 15 clear reference to local procedures and contact information, such as telephone numbers, for local agencies relevant to a protection of vulnerable adults investigation. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 16 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, 20, 24, 26 Clovelly House is well maintained and decorated, offering comfortable, safe accommodation for the service users. Service users said they were happy with the accommodation provided and service user rooms were seen to be comfortable and personalised. EVIDENCE: The environment is clean and well maintained offering good access throughout for service users. There is an 8-person shaft lift assisting access between floors. There are safe and comfortable communal facilities for service users. There is a choice of seating areas. There is a lounge and dining room, which has a separate conservatory area, and an additional conservatory. There is one designated smoking area. Furnishings were noted to be of a high standard with plenty of natural light and domestic lighting. The Inspector observed that the décor was homely in nature, and of a good standard. There is a seating area outside in the garden. There is wheelchair access to the side of the property. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 17 The Registered Provider should carry out and record service user wishes/agreement and risk-assessments in relation to the provision of keys/locks on bedroom doors. The Registered Provider should provide keys/locks to service users as appropriate. The Registered Provider should audit the hand washing facilities available to staff and, where necessary, provide liquid soap and paper towels or alcohol solution in communal bathrooms and toilets. The Registered Provider should consider the replacement of the existing washing machine with an industrial-type machine with a sluice facility to be better able to cope with fouled linen and enhance infection control within the home. At this time the Registered Provider should then introduce the use of dissolving sacks for the handling of fouled linen. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 18 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) 29, 30 The Registered Provider is clearly committed to service user safety and comfort, but needs to ensure that proper systems are in place. EVIDENCE: The home must produce a robust recruitment policy that is based on equal opportunities legislation and references Schedule 2 of the Care Homes Regulations. CRB checks have been obtained for all people working in the home. Staff complete an application form and undergo an interview. Two references are obtained in respect of all staff working at the home and staff are provided with written statements of terms and conditions and a job description. All staff are provided with copies of the GSCC code of conduct. The inspector is satisfied that the service users are protected from harm and that the Registered Provider is thorough and diligent in employing staff. The Registered Provider discussed the possibility of resourcing external guidance, such as Croners publication. The Registered Provider should review and amend the recruitment policy/procedure to ensure compliance with relevant legislation (Equal Opportunities, Employment Law). The Registered Provider should keep a record of interview. There is a clear commitment to staff training with all the staff either undertaking or having completed NVQ Level 2. The Registered Provider is going to undertake the Registered Managers Award. The Registered Provider Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 19 has obtained National Training Organisation induction booklets, but it was not evident that these are in use. The Registered Provider should ensure that all staff undertake induction training compliant with ‘Skills for Care’ units (renamed from TOPSS). Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 20 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, 34, 35, 38 There is no doubt in the inspector’s mind that the Registered Providers know the service users well and the home has functioned effectively for many years. However, the Registered Providers recognise that there is a need to prioritise managerial aspects of care EVIDENCE: The Registered Provider manages the home on a day-to-day basis and is a qualified nurse, registered with the Nursing and Midwifery Council. Other family members work within the home and the family has owned the home for twenty-two years. The Registered Provider’s daughter is currently undertaking the Registered managers’ award and deputises for the Registered Provider. The Registered Provider is very experienced in running the home and has twentyfive years experience of working with Older People. The Registered Provider has booked a place on the Registered Managers Award course later this year. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 21 The Service users were aware of the Announced inspection and spoke freely with Inspector about the home. Comments from the service users were very positive about all aspects of life at Clovelly House. The home has a quality assurance questionnaire which has been circulated to Service Users and visiting relatives. The results of the survey were provided at the Inspection, the Registered Provider undertook to include a summary of responses in the service users’ guide for the benefit of prospective service users. An annual development plan is in operation, though as discussed this will expand to include identified staff training needs (from supervision and appraisal), and any work identified as a result of risk-assessments. The Registered Provider provided a financial statement from the home’s accountants. There is currently no reason to doubt the financial viability of the home. Adequate insurance cover is in place to ensure the protection of service users. The Registered Provider keeps the handling of service user money to a minimum. A record of financial transactions is kept, but could be improved. The Registered Provider should ensure that a receipt is provided for all transactions, and the financial record clearly shows money in, money out, comment (reason), and balance. The Registered Provider must ensure that risk-assessments are recorded to inform and direct maintenance and improvements to the home and care plans (particular attention being given to hot water and the risk of scalding, hot surfaces and the risk of burns, windows and the risk of falls, any potential risk posed by an individual service users behaviour). Risk-assessments must include the identified risk, an action plan, and timescales. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 22 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 2 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 2 x 2 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x 3 3 2 x x 2 Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 23 YES 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 1 Regulation 5 Requirement Timescale for action 01/08/05 2. 38 13 The Registered Provider must produce a Service Users Guide that includes the required information and this must be made available to all Service Users, their representatives and the Commission for Social Care Inspection. 01/08/05 The Registered Provider must ensure that risk-assessments are recorded to inform and direct maintenance and improvements to the home and care plans (particular attention being given to hot water and the risk of scalding, hot surfaces and the risk of burns, windows and the risk of falls, any potential risk posed by an individual service users behaviour). Riskassessments must include the identified risk, an action plan, and timescales. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 24 No. 1. 2. Refer to Standard 2 7 Good Practice Recommendations The Statement of Terms and Conditions would benefit from a more detailed breakdown of fees, how they are paid, and by whom. The care plans should identify the care need, the aim of intervention and the actual intervention to be carried out. The care plan should be THE document that informs carers and should be reflected in the carer’s written entries in the daily records. The Registered Provider should ensure that there are two staff initials when it is necessary to transcribe prescribed medication to a Medication Administration Record. The medication policy in operation should be reviewed and expanded to include the ordering, receipt, storage, administration, disposal and return of medication. The Registered Provider should ensure that information in respect of the dying and death is acquired as part of the pre-admission or admission process. The Registered Provider should review and expand the existing protection of vulnerable adults policy to ensure that it provides clear instruction to staff and clear reference to local procedures and contact information, such as telephone numbers, for local agencies relevant to a protection of vulnerable adults investigation. The Registered Provider should carry out and record service user wishes/agreement and risk-assessments in relation to the provision of keys/locks on bedroom doors. The Registered Provider should provide keys/locks to service users as appropriate. The Registered Provider should audit the hand washing facilities available to staff and, where necessary, provide liquid soap and paper towels or alcohol solution in communal bathrooms and toilets. The Registered Provider should consider the replacement of the existing washing machine with an industrial-type machine with a sluice facility to be better able to cope with fouled linen and enhance infection control within the home. At this time the Registered Provider should then introduce the use of dissolving sacks for the handling of fouled linen. The Registered Provider should review and amend the recruitment policy/procedure to ensure compliance with relevant legislation (Equal Opportunities, Employment Law). The Registered Provider should keep a record of interview. The Registered Provider should ensure that all staff undertake induction training compliant with ‘Skills for Care’ D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 25 3. 9 4. 5. 11 18 6. 24 7. 26 8. 26 9. 29 10. 30 Clovelly House 11. 35 units (renamed from TOPSS). The Registered Provider should ensure that a receipt is provided for all transactions, and the financial record clearly shows money in, money out, comment (reason), and balance. Clovelly House D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 26 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell PL25 4AD 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 D52-D04 S8944 Clovely House V214848 100505 Stage 1.doc Version 1.30 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!