Inspection on 15/08/07 for Clovelly House

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Clovelly House 21/06/06

Clovelly House 10/06/05

Clovelly House 14/02/05

Clovelly House 17/01/05

Clovelly House 13/10/04

Clovelly House 30/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Clovelly House Rear of Elm House March Cambridgeshire PE15 8PS Lead Inspector Alan Buttery Unannounced Inspection 15th August 2007 10:00 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 Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clovelly House Address Rear of Elm House March Cambridgeshire PE15 8PS 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) 01354 655768 01354 661806 Mr Malcolm Laurence George Angela Grant Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 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. Fees range between £343.00 and £430.00 a week. A copy of the last inspection report was available on the hall table for people to read, together with other information for both people living in the home and visitors. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit and looked at the key standards for older people. The home is registered for up to 21 people, but operating with 20 as a double room is now used as a single, and all rooms are full. A stable staff team is in place, with no current vacancies. The providers submitted an annual quality assurance assessment, and information form this is contained within the report. The assessment shows that 13 of the 20 people living in the home fund their own care, and that 5 people have moved into the home in the last twelve months. What the service does well: What has improved since the last inspection? What they could do better: There were no areas identified during the inspection that needed specific mention. The service do an ongoing improvement programme, with further Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 6 redecoration and replacement carpeting planned. Improvements to the laundry facilities are planned for the coming year. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Detailed information is obtained for anyone wishing to move into the home to ensure that any identified needs will be met. EVIDENCE: The home has a policy and procedure to manage new admissions, and before any one new moves into the home, the manager visits them, often accompanied by one of the senior carers, and gathers all relevant information about the person and their needs, to ensure that they are able to meet the individuals needs. Information is also obtained from the commissioners where the package is being paid for by the local authority. Three files were examined relating to people living in the home, including one for a recent admission, and all the required information was in place, including a good social history of the person moving to the home. The home does not offer intermediate care. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual plans detail the support needs of people living in the home, and how these needs should be met ensuring that the people are treated with dignity and respect. EVIDENCE: Individual files are kept for everyone living in the home, as well as detailed care plans, and the files include the initial assessment information, daily records, review notes, health records and any other relevant information. Four care plans were examined during the inspection, and provide carers with information to help them support the individuals. The care plans could be further improved, with more emphasis on the outcomes sought for the people living in the home. Health needs are recorded within the files, and evidence was seen of professional consultation with a range of health professionals, including GP’s and district nurses, continence advisors and dieticians. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 10 The home has a suitable policy on medication, and since the last inspection, have changed to a new pharmacist, and feel their relationship with them is better than previously. They have also improved the facilities for storing medication. One of the people living in the home is able to partly manage their own medication, and have suitable storage facilities in their room. A risk assessment has been done to ensure the safety of this arrangement, which is kept monitored. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People living in the home help to plan variety of activities and events for themselves and their families, both in the home and the local area. EVIDENCE: The home continues to offer a good selection and range of activities and events both within the home and in the local area. A recent garden party raised over £600 for the home’s amenity fund, which is used to subsidise events, lunches when out and transport costs. This is an annual event which is advertised locally and attracts people in the local area as well as those living in the home and their families, keeping the home involved in the local community. They also invite relatives of people who lived in the home before their death, and it is good to see a home that maintains this type of contact. Other visits have included a trip to an animal shelter, visits to local pubs and restaurants, shopping trips, visits to garden centres and walks in the local area. Earlier in the summer the home had a strawberry tea in the gardens, and one of the people living in the home helped to arrange this, designing invitations and pictures. The home keeps a photographic record of these events which is always available for people living in the home to look at. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 12 In house activities include bingo, entertainment, cake stalls, as well as newspapers and magazines, and regular meetings held for the people living in the home are used to discuss things they would like to be able to do. A good range of meals are available, with a good choice, again discussed at residents meetings, and providing variety and nutrition, with help where needed for local dieticians. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to protect people living in the home from abuse, and to ensure any comments or concerns are listened to and acted on. EVIDENCE: The service has a complaints policy in line with the minimum standards, which ensures that if any complaints are received, they are dealt with inn appropriate manner and within set timescales. A copy of the complaints procedure is included in the service user guide, and a copy of the guide given to everyone living in the home. A further policy provides guidance for staff in adult protection matters, and all staff receive training in POVA as part of their initial induction and regularly thereafter. Further training is already booked between October and December this year. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The service provides a homely style of living in pleasant and clean surroundings, with well maintained gardens, accessible to everyone living in the home. EVIDENCE: Although originally based in an older building, which has been extended, the environment is very well maintained and decorated, and provides a comfortable, but homely, atmosphere for the people living there. The home has very attractive gardens, which are well maintained and used by a number of the people living in the home, and for activities and events. Since last year, additional decking areas and a ramp have been put in, improving the accessibility of the garden to people living in the home with mobility difficulties. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 15 The manager indicated some further improvements she is hoping to make this year, along with day to day redecoration, and the annual quality assurance assessment sent in as part of this inspection also indicated plans to improve the laundry facilities in the home. During a tour round the home, it was seen to be clean and tidy in all areas, and there were no unpleasant odours noted. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A well trained team of staff are available to support the people living in the home at all times. EVIDENCE: An established staff team is in place to ensure the needs of people living in the home can be met. Since the last inspection, the deputy manager of the service has left, but rather than replacing her, the registered manager has delegated a number of tasks to senior carers, who appear to be thriving on the additional responsibilities, and the staff team as a while are very positive and committed. Staff retention remains very good. Recruitment procedures remain very good, and staff files examined during the visit all indicated that the necessary checks and information are all in place, including application forms, at least two written references, CRB and POVA checks, training records and health declarations. Staff all receive training, both mandatory such as moving and handling, fire safety, first aid and food hygiene and more specific to the people they look after including dementia care, catheter care and treating people with empathy and compassion. All established staff members have completed level 2 NVQ training, and are now being enrolled onto level 3 training if they have not already achieved this. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that people living and working in the home are not at placed at risk, and people living in the home are able to make any views they have about the service known to the management. EVIDENCE: The home is very well managed, and changes introduced since the deputy manager left at Christmas have improved the management and efficiency in the service. For example, delegation of a number of tasks to senior carers has allowed the manager to consider and introduce a number of changes, and new documentation. Regular meetings are held between the manager and the registered person, and staff commented on the open and approachable style of management. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 18 Service users all appeared happy and content, and those who spoke to the inspector during the visit were very happy with the support they receive, and the facilities in the home. An annual quality assurance check ensures that the views of the people living there as well as their relatives are taken into account, and regular meetings give those living in the home a chance to discuss what is happening and any changes they would like to see. Health and safety procedures are in place to ensure that the people either living or working in the home are not placed at risk, and regular maintenance checks are carried out. All staff receive health and safety training. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Individual care plans should look at the outcomes expected for the people receiving the support. Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clovelly House DS0000015292.V350632.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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