Inspection on 08/11/05 for Clovelly House

This inspection was carried out on 8th November 2005.

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 18/07/06

Clovelly House 10/05/05

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 Kerensa Livingstone Unannounced Inspection 8th November 2005 09:30 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 DS0000008944.V254795.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clovelly House Address 18 St Michaels Road Newquay Cornwall TR7 1RA 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) 01637 876668 01637 879958 Mrs June Anastasia Hartigan Mrs June Anastasia Hartigan Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 19 adults of old age (OP) Total number of service users not to exceed a maximum of 19 Date of last inspection 10th May 2005 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 gardens, slightly off the road, with a small parking area to the rear of the property. 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/smoking 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-today basis, with the support of the family. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection, the Inspector looked at records, care plans, Policies and Procedures and the environment. The Inspector met with the Registered Provider, staff and spoke with nine of the Service Users. Clovelly House provides a comfortable home with a relaxed family atmosphere, and the evident contentment of the service users impressed the Inspector. Service users were evidently well cared for and expressed only positive comments about the home, Provider and the staff. What the service does well: What has improved since the last inspection? What they could do better: The Registered Provider must sustain the improvements that have been made and prioritise the management aspects of the home, such as developing policies and procedures e.g. employment, finances, duty rota, risk assessments. Environmental risk assessments have been undertaken, action must be taken within the timescales set by the assessor (particular attention Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 6 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. All Service Users rooms are yet to be provided with a lockable door. 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 DS0000008944.V254795.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 The service users are well informed, assessed prior to moving into the home and enabled to make an informed choice about their new home. EVIDENCE: The Statement of Purpose and Service Users Guide have been made available in all Service Users rooms, this has been recently reviewed. The Inspector was informed that the combined document is provided to all prospective Service Users. An addendum has been added to the contract as recommended at the last inspection to clarify the breakdown in fees, how they are paid and by whom. There is evidence that these are being provided for Service Users. Prospective service users and their representatives are invited to look at the home before admission. One Service User described how she was welcomed and helped to settle into the home. She described the process as a positive experience. The Registered Provider who is a registered nurse assesses prospective service users prior to admission, either in their own home or in Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 9 hospital, to ensure the home can meet their needs. The home has one vacancy, emergency admissions are avoided. The Registered Provider was able to demonstrate a good understanding of the service user’s care needs and capabilities. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 & 10 The service user health, personal and social care needs are fully met by the Registered Provider and her staff. Specialist advice is sought on an individual basis. Service Users stated that they are respected and their need for privacy acknowledged. EVIDENCE: A new system of record keeping has been introduced. All Service Users have a care plan this has been significantly improved to cover all aspects of personal, social and health care needs. These are signed by the Service User and reviewed monthly. The daily record requires further development to reflect the Service Users day. There is considerable evidence that service users’ health care needs are well met at the home. Specialist nursing care and equipment is provided where needed. All Service Users are registered with a General Practitioner. Service users are provided with access to regular activities, including keep-fit sessions. There is evidence that Service Users have access to a broad range of Health care professionals such as Ophthalmology, Chiropody, Optician and Dentist Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 11 according to their individual needs. Service Users spoke highly of the staff and their ability to meet their needs. Two staff sign when it is necessary to transcribe prescribed medication onto a Medication Administration Record as recommended at the previous inspection. The medication policy in operation has been reviewed, however it still needs to be further expanded upon, for example to include Home Remedies, countersigning MAR sheets, Insulin administration. Service user wishes in respect of dying and death are recorded in the documentation as recommended at the previous inspection. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 & 14 Service Users are enabled to make choices about how they live their lives and their autonomy is respected. Visitors are welcomed to the home. EVIDENCE: There are no restrictions on visits from families or friends of service users and the Inspector observed visitors coming and going from the home during the course of the inspection. There is an additional lounge where Service Users can receive their visitors privately, if they do not wish to see them in their room. One Service User informed the Inspector that this home compared very favourably to another one they had resided in. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 13 All staff receive training on the Service Users right to privacy and freedom of choice. Service users stated that they were able to choose whether to participate in activities or to spend time in their room. Service Users informed the Inspector that the Registered Provider and her family work very hard to create a very homely, comfortable atmosphere. A timetable of social activities is made available on the notice board this included keep Fit, table games, Blind Club, Bingo and visits out within the local community. The Roman Catholic and Church of England Ministers visit the home regularly, in addition to any individual requests. On the day of the unannounced inspection the Hairdresser visited in the morning and the League of Friends were visiting to sell Christmas cards, table top sale and Tombola in the afternoon. Recent outings include the Newquay Zoo, Lappa Valley Railway and a Christmas visit is planned later this month to a local garden centre. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 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 the following standard(s): 18 The Registered Provider ensures that staff are aware of how Service Users are to be protected from the risk of abuse. EVIDENCE: 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 has reviewed the protection of vulnerable adults procedure to ensure that it provides clear instructions to staff. This document is to be finalised and evidence available at inspection that all staff have read and understood it. An Elder Action against abuse poster is on the office wall. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 15 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): 21, 22, 23, 24, 25 & 26 Clovelly House is well maintained and decorated, offering comfortable, homely, safe accommodation for the service users. Service users said they were very 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. Service users are provided with well-furnished, comfortable and spacious Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 16 bedrooms, most of which have full en suite facilities. All have sink units. One room is registered as a double, however it is used for single occupancy, therefore all Service Users are accommodated in single rooms. Bedrooms are personalised with Service Users own furniture, fittings and pictures. All rooms are provided with a lockable space for valuables. Door locks are due to be fitted to the rooms. Service Users like the environment and how it is kept, they informed the Inspector. Toilet, washing and bathing facilities meet the needs of service users. All of the rooms have washbasins and nearly all are provided with en suite toilets. In addition there are 3 toilets downstairs and a bathroom with an electric hoist and a further 2 bathrooms and 3 toilets upstairs. One of these has a manual hoist. All facilities offering full immersion have been regulated and some hot surfaces covered. Risk assessments have been completed for environmental risks within the home, as required from the last inspection. However action must be taken within the identified timescales. All windows are restricted. Since the last inspection, an audit of the hand washing facilities has been completed, liquid soap and paper towels have been provided. Staff were observed to use an alcohol solution in addition to this. There are designated cleaning staff and the home was observed to be clean and hygienic on the day of the unannounced inspection. The Registered Provider is due to replace the existing washing machine with an industrial-type machine with a sluice facility over the next six months and introduce the use of dissolving sacks for the handling of fouled linen. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 17 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. The Registered Provider is clearly committed to training for all staff and to ensuring that service users are safely cared for by the staff within the home. EVIDENCE: The Inspector observed an improvement in the Recruitment procedures, a record of the interview is being kept, Criminal Records Bureau checks have been obtained for all people working in the home. New 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 duty rota must be kept up to date and reflect the persons who are working in the home. The Registered Provider should review and amend the recruitment policy/procedure to ensure compliance with relevant legislation (Equal Opportunities, Employment Law). There is a clear commitment to staff training with all the staff either undertaking or having completed NVQ Level 2. Six out of the twelve staff have completed it, with four more studying for their National Vocational Qualification Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 18 Level 2. The Registered Provider and her daughter are undertaking the Registered Managers Award. The Registered Provider has obtained National Training Organisation induction booklets and there is evidence that the newest member of staff is completing this. All new staff must complete this induction. Service Users spoke very highly of the staff and their ability to perform their job. This is further evidenced by the atmosphere within the home and interactions between the Service Users and the staff. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 19 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): 32, 36 & 37. The Registered Provider demonstrates clear leadership, knows the service users well and the home has functioned effectively for many years. Over the last year there has been a significant improvement in the managerial/record keeping aspects to the running of the home. EVIDENCE: The home has a pleasant, restful atmosphere. There is evidence of a clear sense of direction and leadership. The Registered Provider manages the home on a day-to-day basis and is a qualified nurse, registered with the Nursing and Midwifery Council. The Registered Provider is supported by her daughter, they are both undertaking the Registered Manager’s Award. Other family members work within the home and the family has owned the home for over twenty-two years. The Service Users stated that they are very happy with the staff, care Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 20 and services provided at the home. They spoke particularly highly of the Provider and the family. Qualitative information is being gathered and will be formalised into a report. This information will be included within the Service Users guide and a copy forwarded to the Commission for Social Care Inspection. The Registered Provider keeps the handling of service user money to a minimum. It was recommended at the previous inspection that a record of financial transactions is kept, but this has yet to be done. 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 is in day-to-day control of the home and available to staff at all times. Formal, recorded supervision of staff has been commenced and is taking place regularly. Annual appraisals are conducted with all staff. There is a Visitor’s Book, which is used for recording all visitors to the home. There has been a significant improvement in the record keeping and working towards meeting the National Minimum Standards, it is important that this is sustained to match the positive Service User experience of living at Clovelly House. Service users’ personal records are kept locked in the office when not in use. The requirement of notifying the Commission for Social Care Inspection under Regulation 37 was discussed. The Registered Provider must ensure that risk-assessments inform and direct maintenance and improvements to the home. Risk-assessments have been compiled, however action must be taken within the identified timescales. Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 21 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 3 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X x 3 3 x Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 22 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 OP24 Regulation 12(4a) Requirement The Registered Provider is required to ensure that the care home is conducted in a manner which respects the privacy and dignity of the Service Users e.g. provision of door locks. The Registered Provider must keep a copy of the duty roster of the persons working within the care home and whether the roster was actually worked. Timescale for action 31/03/06 2. OP27 17(2), Sch. 4 08/11/05 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 OP29 Good Practice Recommendations 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 ensure that a receipt is provided for all transactions and the financial record clearly shows money in, money out, reason and balance. DS0000008944.V254795.R01.S.doc Version 5.0 Page 23 2. OP35 Clovelly House Clovelly House DS0000008944.V254795.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall 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. 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