Inspection on 21/06/06 for Clovelly House

This inspection was carried out on 21st June 2006.

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 15/08/07

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 44 Station Road March Cambridgeshire PE15 8LE Lead Inspector Alan Buttery Key Unannounced Inspection 30 June 2006 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.V298451.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.V298451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clovelly House Address 44 Station Road March Cambridgeshire PE15 8LE 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.V298451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 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. Fees range between £340.00 and £440.00 a week. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection of the home, and on the day of the inspection, the homes manager was off duty. The deputy manager assisted the inspector, providing the information and records required. Service users and staff were spoken to, a tour of the building was undertaken and documentation was read. The home is currently full, and fees range between £340.00 and £440.00. The staff team remain stable, with no current vacancies. What the service does well: 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 DS0000015292.V298451.R01.S.doc Version 5.2 Page 6 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.V298451.R01.S.doc Version 5.2 Page 7 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): 3 and 6 Quality in this outcome area is Good. This judgement has been made using available evidence and a visit to the premises. Detailed assessments are carried out and service users and families encouraged to visit the home to ensure their needs will be met. EVIDENCE: The home has a comprehensive admissions policy, and ensures that detailed assessment information is obtained from all relevant sources prior to a new admission taking place. This information was seen on service user files examined, and included details of service users social history as well as health and social needs and financial information. The records examined included the most recent admission to the home as well as a service user who had been there for some time. The home does not offer intermediate care. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is Good. This judgement has been made using available evidence and a visit to the premises. Individual plans ensure care staff have sufficient information to meet service users needs, and policies and procedures ensure medication is administered safely. EVIDENCE: All service users have individual files, which include care plans, risk assessments, health records, daily notes, review notes, assessment information and other relevant information, and from this it was clear that service users needs are identified and care staff are aware how these needs should be met. The home has a policy on the administration of medication, and ensures that all staff involved with the administration of medication receive the necessary training. From discussions with service users and staff it is clear that staff ensure that service users are treated with dignity and respect, and that their privacy is maintained at all times. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 9 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, 13, 14 and 15 Quality in this outcome area is Excellent. This judgement has been made using available evidence and a visit to the premises. A variety of activities are available, and service users can choose what to engage in, and help to arrange, involving families wherever possible. EVIDENCE: From the discussions with the staff and service users, and observation during the inspection, it was clear that the home continues to provide a high level of activities to service users living in the home. Activities planned over the summer include a garden party, regular visits to Band concerts in the local park, trips out to garden centres and other attractions, regular bingo and entertainment. In addition, other ad hoc or in house activities take place, service users visit the local shops, listen to music and watch the new large screen television that has been installed. Service users helped arrange a recent strawberry tea, designing their own invitations and inviting family and friends. Service users receive an appetising choice of freshly prepared meals, and advice and guidance is taken from dieticians and nutritionists where necessary. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 10 Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 11 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 and 18 Quality in this outcome area is Good. This judgement has been made using available evidence and a visit to the premises. Policies and procedures are in place to ensure issues are dealt with. EVIDENCE: The homes complaints policy ensures that any issue is dealt with in accordance with the regulations, and a recent complaint that had been received was discussed in detail. Although the home felt that the issues raised had been dealt with, it is clear that they were able to use the information offered by a family to guide and improve their practice further. Staff all receive training and guidance in adult protection issues, last year but it felt that this is an area where continuing training and updates needs to be in place, to ensure that any concerns would be appropriately dealt with. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 12 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 and 26 Quality in this outcome area is Good. This judgement has been made using available evidence and a visit to the premises. The home is comfortable, clean and well maintained. EVIDENCE: Since the last inspection, the rear lounge has been redecorated, and new televisions fitted in both lounges, and the home remains in excellent order. Domestic staff ensure that the home is kept clean and tidy, and on the day of the inspection, the rooms all smelt fresh, with no unpleasant odours. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 13 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, 29 and 30 Quality in this outcome area is Adequate. This judgement has been made using available evidence and a visit to the premises. Areas of improvement were identified and agreed. EVIDENCE: The home continues to have a very stable staff team, with few changes, and at the present time has a full complement of staff, with a suitable mix of experience at all times. Recruitment procedures ensure that service users are not placed at risk, and staff files were examined to ensure that the required checks are made. A good variety of training is available, but training should be arranged as a matter of urgency to ensure all staff are aware of POVA procedures. The home was asked to provide a training matrix for the coming year It was also recommended that some more specific dementia care training be provided to all care staff. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 14 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): 31, 33, 35 and 38 Quality in this outcome area is Good. This judgement has been made using available evidence and a visit to the premises. The home is well managed, and the health and welfare of service users and staff maintained. EVIDENCE: It is clear from discussions with service users and staff that the manager of the home is well regarded, and the management team functions well, with the interests of service users always to the fore. Policies and procedures are in place to ensure service users finances are managed, and although a discrepancy in the recording of one service users monies was noted, this was clearly a lapse in the recording of one item. Health and safety training is provided to all staff, although updates for the current year have yet to take place, and all equipment is kept maintained at all times. Records of the maintenance of fire alarm systems, electrical appliances, hoists, lifts and the heating system were examined and were satisfactory. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 15 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X X Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 16 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. 1 Standard OP30 Regulation 18(1)(c) Requirement A schedule of training arranged for the current year must be supplied to the CSCI detailing the training planned. Accurate records of money held on behalf of the service users must be maintained. Timescale for action 31/08/06 2 OP35 17(2) 10/08/06 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 OP30 Good Practice Recommendations Specific training in dementia care issues should be provided to all staff. Clovelly House DS0000015292.V298451.R01.S.doc Version 5.2 Page 17 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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 DS0000015292.V298451.R01.S.doc Version 5.2 Page 18 - 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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