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Inspection on 05/09/06 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 5th September 2006.

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 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 premises were clean, homely and well maintained. The garden was attractive and seating had been provided.. Residents expressed satisfaction with the care and meals provided. The manager and her staff were knowledgeable regarding the care of the residents. Staff had been provided with essential training. All requirements made in the previous inspection report had been responded to.

What has improved since the last inspection?

Case records of residents now routinely contain a recent photograph of each resident. The registered person had ensured that all new staff receive appropriate fire training. Hospital admissions are reported to the Commission in Regulation 37 Notices.

What the care home could do better:

The registered person must ensure that the home`s emergency lighting is checked monthly and this is documented.

CARE HOMES FOR OLDER PEOPLE Clovelly House Residential Home Ltd 83-89 Torrington Park London N12 9PN Lead Inspector Daniel Lim Key Unannounced Inspection 5th September 2006 09:05 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 Residential Home Ltd DS0000010400.V307756.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 Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clovelly House Residential Home Ltd Address 83-89 Torrington Park London N12 9PN 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) 020 8445 6775/1175 020 8445 7651 clovellyhouse@tiscali.co.uk Clovelly House Residential Home Limited Mrs Catherine Frances Thorn Care Home 39 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number disorder, excluding learning disability or of places dementia (0), Old age, not falling within any other category (0) Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Six service users. A maximum of six service users aged 40 years and over, can be within the category of mental disorder, excluding learning disability or dementia. 23rd January 2006 Date of last inspection 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 homes 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. The fees charged by the home range from £450 - £495 per week. The provider must make information about the service available (including reports) to service users and other stakeholders. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 5 September 2006. The inspection took a total of four hours to complete. The inspector found that the overall quality of care provided was good. During this inspection, the inspector was assisted by the manager (Mrs Frances Thorne). The inspector was able to interview four residents and two visitors to the home (a church worker and the community nurse). The feedback received from them indicated that they were satisfied with the care provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home. The premises including residents’ bedrooms, treatment room, communal rooms, laundry, kitchen and gardens were inspected. Three staff on duty were interviewed on a range of topics associated with their work. Staff records, including supervision records, evidence of CRB disclosures, references and training records were examined. In addition, the minutes of staff and residents’ meetings were examined. Nine completed questionnaires were received from residents. These were positive and indicated that residents were satisfied with the care provided. Completed questionnaires were also received from relatives (20), social and healthcare professionals (12) and local authority placement officers (2). These indicated that the respondents were satisfied with the care provided for residents. What the service does well: The premises were clean, homely and well maintained. The garden was attractive and seating had been provided.. Residents expressed satisfaction with the care and meals provided. The manager and her staff were knowledgeable regarding the care of the residents. Staff had been provided with essential training. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 6 All requirements made in the previous inspection report had been responded to. 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 Residential Home Ltd DS0000010400.V307756.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 Residential Home Ltd DS0000010400.V307756.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Arrangements were in place to ensure that residents’ aspirations and needs are assessed. This ensures that their needs can be identified and met at the home. EVIDENCE: The four residents who were interviewed indicated that their care needs had been met at the home and they were happy with the care provided. Comments made included, “well treated” and “well cared for”. A sample of four residents’ case records which were examined, contained comprehensive assessments. Risk assessments together with strategies for minimising risks had been prepared. The manager informed the inspector that the home does not provide intermediate care. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 9 Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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, 9, 10 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents had been well treated and arrangements were in place to ensure that the healthcare and personal needs of residents are attended to. EVIDENCE: The four residents interviewed, indicated that their healthcare needs had been met. Comments made included, “yes, I have seen the doctor” and “my medication has been given to me”. 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 documented. A record of GP visits, appointments with the dentist, chiropodist and optician had been recorded. Residents were able to confirm that they had been given their medication. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 11 The visiting community nurse confirmed that there was close liaison with the home and the healthcare needs of her patients had been attended to. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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, 15 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life and routines of residents were well organised. This ensures that residents feel valued and are able to exercise choice and control over their lives. EVIDENCE: There was evidence that residents had been visited by their families. This was confirmed in the completed questionnaires received. The bedrooms inspected had been personalised by residents with personal items such as photos and souvenirs. The kitchen was clean. A record of fridge and freezer temperatures had been kept. A fire blanket, fly electrocutor and first aid box were in place. The menu was examined and found to be varied and balanced. The four residents who were interviewed stated that they were satisfied with the meals provided. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 13 A local church representative was vsiting residents in the home during the inspection. He confirmed that meetings were held for those who wanted to attend it a religious service. The inspector was also provided with a programme of daily social and therapeutic activities. This included local walks, discussion sessions, exercise and music sessions. The four residents interviewed were on the whole satisfied with the social activities provided. The issue of equalities was discussed. The manager was aware of the need to treat residents with respect and dignity regardless of their any disability they may have, their race, religion or sexual orientation. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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): 16, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents are well treated and protected from abuse. EVIDENCE: The complaints record was examined. Complaints recorded had been promptly responded to. There was evidence that staff had been provided with instruction and training on adult protection. All residents who were interviewed stated that they had been well treated and no complaints were received by the inspector. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean and maintained to a high standard, therefore providing a pleasant environment to live in. EVIDENCE: The premises were clean and well furnished. Residents who were interviewed stated that they were happy with the accommodation provided. Bedrooms visited had been personalised by residents concerned and appeared cosy. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 16 The required maintenance and safety inspection documents were seen by the inspector. These included safety inspections carried out on the lift, hoists, portable appliances, electrical installations and gas equipment. The laundry was inspected and staff interviewed were aware of the need to wash soiled and infected laundry in a hot wash cycle (over 65C for a minimum of 10 minutes). Clothes which had been washed were found to be clean and neatly folded. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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, 29, 30 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing arrangements were satisfactory. This ensures that residents are supported by a competent and effective staff team. EVIDENCE: Residents who were interviewed indicated that staff had treated them with respect and dignity. The duty rota was examined. It indicated that in addition to the manager and ancillary staff, there was normally at least 6 care staff during the morning shift, 4 care staff during the afternoon and evening shifts and 3 care staff on waking duty during the night shifts. No concerns regarding staffing were brought to the attention of the inspector by those interviewed. Staff who were on duty were interviewed on a range of topics associated with their work (such as health and safety, adult protection, fire procedures and the healthcare of residents). They were noted to be knowledgeable regarding their roles and responsibilities. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 18 There was evidence that staff had been provided with essential training and instruction. This included food hygiene, adult protection, moving and handling, care of residents with dementia and health and safety. The staff records examined indicated that the required recruitment standards and procedures (including obtaining satisfactory CRB disclosures and references) had been followed. Staff further stated that they worked as a team and had been supported by their manager. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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): 31, 33, 35, 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Systems were in place to ensure that the home is effectively managed and to protect the interests and welfare of residents and staff. However, one improvement is required in the area of health and safety. EVIDENCE: The manager was noted to be knowledgeable regarding the management of the home. All residents interviewed were satisfied with the care provided. Compliments had been received from relatives and these were available for inspection. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 20 The fire log book was examined. The weekly fire alarm tests had been documented. Fire drills had been documented. The home has an up to date fire risk assessment. The emergency lighting had not been checked at least once a month. This is required to ensure that any defect is promptly responded to. A current certificate of insurance was displayed. The accounts of the business were not available during the inspection. A statement was later received from the company’s accountants which indicated that the business was financially viable. Residents interviewed confirm that they were regularly consulted regarding the management of the home. The minutes of a recent meeting were available for inspection. The minutes of staff meetings were also available for inspection. There was evidence of effective quality monitoring. Reports of recent consumer surveys were available for inspection. Recommendations had been made for improving the service provided. The financial record of a resident was available for inspection (only one resident’s money was kept by the home). This record contained receipts for items purchased on behalf of the resident. Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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 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 3 3 3 3 3 3 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 2 Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 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 OP38 Regulation 13(4)(c) 23(2)(c) Requirement Timescale for action 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clovelly House Residential Home Ltd DS0000010400.V307756.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Southgate Area Office 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 DS0000010400.V307756.R01.S.doc Version 5.2 Page 24 - 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!