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Inspection on 20/04/05 for Clovelly House Residential Home Ltd

Also see our care home review for Clovelly House Residential Home Ltd for more information

This inspection was carried out on 20th April 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.

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

What the care home does well

The home was clean and well furnished. No offensive odours were detected. The required records asked for were available for inspection. These were well maintained and up to date. Staff were alert and knowledgeable regarding their responsibilities and when questioned, they were aware of the care to be provided and the home`s various policies and procedures. Arrangements were in place to ensure that the healthcare needs of residents were attended to. Residents were observed to be clean, appropriately dressed and appeared well cared for.

What has improved since the last inspection?

Residents stated that they were not woken up against their wishes. A quality assurance report was available

What the care home could do better:

One recommendation which was made in the last inspection has been repeated in this report. This is related to staff training.

CARE HOMES FOR OLDER PEOPLE Clovelly House Residential Home 83-89 Torrington Park Finchley London N12 9PN Lead Inspector Daniel Lim Unannounced 20 April 2005 at 06.00 am 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 Residential Home Ltd L Version 1.10 Page 3 SERVICE INFORMATION Name of service Clovelly House Residential Home Limited Address 83-89 Torrington Park, Finchley, London N12 9PN 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) 020 8445 6775 020 8445 7651 Clovelly House Residential Home Limited Mrs Catherine Frances Thorn CRH (PC) 39 Category(ies) of Dementia - over 65 years of age (39), Mental registration, with number disorder, excluding learning disability or of places dementia (6), Old age, not falling within any other category (39) Clovelly House Residential Home Ltd L Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 A maximum of six service users aged 40 years and over, can be within the category of mental disorder, excluding learning disability or dementia. Date of last inspection 31/1/05 Brief Description of the Service: Clovelly House is a care home registered to provide personal care for a maximum of 39 residents who are over 65 years of age and who may have dementia. The home’s conditions of registrations has also been varied to allow it to provide care for six adults with a mental disorder who are over forty years of age. The stated aims of the home are to provide a secure, relaxed and homely environment in which care, personal well being and comfort are of prime importance. The home consists of four adjoining houses which have been converted to their present use. Bedrooms are situated on all three floors of the home. The lounges and dining room are on the ground floor. All floors are served by a shaft lift. There are thirty six single bedrooms and three shared bedrooms. The home has five lounges and a dining room. Clovelly House is located in a residential area within walking distance of shops, cafes, and other community facilities located along the high road in North Finchley. Clovelly House Residential Home Ltd L Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 20 April 2005 and took three hours to complete. The inspectors (Daniel Lim & Brian Bowie) found that all of the National Minimum Standards examined had been met and the overall quality of care provided was good. During this inspection, the inspector was accompanied by the manager of the home (Mrs Catherine Frances Thorn). The inspectors were able to interview four residents. The feedback received from three of them regarding the care provided was positive and they indicated that their needs had been met. One resident expressed uncertainty regarding the appropriateness of his placement. This was looked into by the inspectors. What the service does well: What has improved since the last inspection? Clovelly House Residential Home Ltd L Version 1.10 Page 6 Residents stated that they were not woken up against their wishes. A quality assurance report was available What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clovelly House Residential Home Ltd L Version 1.10 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 Residential Home Ltd L Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 The manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs are met. Three residents who were interviewed stated that their needs had been met and they were well cared for. EVIDENCE: Residents were noted to be clean and appropriately dressed. Four case records which were examined, contained comprehensive assessments of the needs of residents. A resident who was interviewed stated that he was not completely happy with certain aspects of his placement. This was discussed with the manager. The manager was able to provide the inspector with documented evidence that this resident’s care had been reviewed recently and his concerns responded to. Clovelly House Residential Home Ltd L Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11 The personal and healthcare needs of residents had been met at the home. Residents who were interviewed stated that they had also been treated with respect and dignity. EVIDENCE: Feedback from the four residents interviewed, indicated that their healthcare needs had been met. The sample of four case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were available. Staff interviewed were knowledgeable regarding the care to be provided to residents. Residents were observed to be clean and appropriately dressed on the day of inspection Clovelly House Residential Home Ltd L Version 1.10 Page 10 The medication administration charts examined had been appropriately signed. The temperature of the treatment room and medication fridge had been monitored daily and found to be satisfactory. Residents interviewed stated that they had been given their medication. Clovelly House Residential Home Ltd L Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 The personal preferences of service users had been respected. This included waking up routines. EVIDENCE: The inspectors interviewed four of the five residents who were awake when they arrived. Residents stated that they had not been woken up against their wishes. The fifth resident was asleep in her chair and the inspectors did not want to disturb her. Staff who were interviewed stated that they had been instructed to respect the preferences of residents regarding their waking up routines. The home had a policy and procedure regarding respecting the preferences of residents regarding their waking up preferences. Clovelly House Residential Home Ltd L Version 1.10 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The rights of residents had been protected and complaints had been taken seriously. Residents are protected from abuse. Residents interviewed stated that they had been well treated. EVIDENCE: The home had a record of complaints made and there was evidence that these had been promptly dealt with. Staff interviewed stated that they had been provided with training on adult protection and when interviewed, they were knowledgeable regarding the procedures to be followed when responding to allegations made. One resident stated that he was not fully satisfied with the service provided in the home. This was discussed with the manager who provided the inspectors with documented evidence that his dissatisfaction had been responded to. Clovelly House Residential Home Ltd L Version 1.10 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,26 Residents interviewed stated that they were happy with the accommodation provided. The home was clean, well maintained and safe. EVIDENCE: The communal areas were inspected and found to be clean. No offensive odours were detected. Washing and toilet facilities were adequate. Bedrooms were not inspected as the inspectors did not want to disturb residents who were still sleeping. Clovelly House Residential Home Ltd L Version 1.10 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff were trained and competent. Residents spoke positively of staff and they were protected by the home’s recruitment procedure. EVIDENCE: Residents interviewed indicated that they were well treated by staff. The sample of staff records examined, indicated that the required recruitment procedures had been followed. This included satisfactory CRB disclosures and a comprehensive induction programme. Staff had been provided with essential training and staff interviewed were knowledgeable regarding their role and responsibilities. The staffing levels provided were lower than that recommended by the residential forum. The manager had been required to carry out a staffing review.This indicated that although the hours provided were lower that that recommended, no concerns had been expressed and the staffing levels appeared adequate. Clovelly House Residential Home Ltd L Version 1.10 Page 15 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) 31,36,38 The manager was competent and knowledgeable regarding the management of the home. The home was well run. The rights and interests of residents had been safeguarded. Health and safety arrangements were in place to ensure the welfare of residents and staff. EVIDENCE: Fire records examined contained details of fire drills and weekly fire alarm checks carried out. Staff records examined contained details of supervision sessions provided. Clovelly House Residential Home Ltd L Version 1.10 Page 16 Systems were in place to ensure that the quality of care provided was closely monitored. No health and safety deficiencies were noted in the areas inspected. Clovelly House Residential Home Ltd L Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 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 Standard No 16 17 18 Score 3 x 3 3 x x x x 3 x 3 Clovelly House Residential Home Ltd L Version 1.10 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 28 Good Practice Recommendations The registered person is strongly advised to undertake all appropriate steps so as to ensure compliance with the requirement that 50 of staff are trained to minimum NVQ 2 level by the end of 2005. Clovelly House Residential Home Ltd L Version 1.10 Page 19 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 Residential Home Ltd L Version 1.10 Page 20 - 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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