Inspection on 21/08/06 for Clover Lodge Care Home

This inspection was carried out on 21st August 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

Clover Lodge Care Home 06/08/07

Clover Lodge Care Home 28/02/06

Clover Lodge Care Home 25/11/05

Clover Lodge Care Home 24/11/04

Clover Lodge Care Home 01/06/04

Clover Lodge Care Home 04/02/04

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Clover Lodge Care Home 68a Humberston Avenue Humberston North East Lincs DN36 4SU Lead Inspector Stephen Robertshaw Unannounced Inspection 21st August 2006 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 Clover Lodge Care Home DS0000002858.V296192.R02.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. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clover Lodge Care Home Address 68a Humberston Avenue Humberston North East Lincs DN36 4SU 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) 01472 816183 01472 211785 mbebbington@cloverlodge.fsnet.co.uk Mr Gilfred Robert Bebbington Mr Mark Gilfred Bebbington Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Clover Lodge Residential Care Home is a family-owned home situated in the village of Humberston, just outside Grimsby. It is within easy access to local bus routes. Clover Lodge provides a homely environment for up to sixteen people over the age of sixty-five years and under no other category. There is a well-maintained garden at the rear of the property with a patio area and a small courtyard at the side encompassing a water feature and pots of flowers. The home has parking spaces for approximately five to six cars at the side of the building. The home is a single storey building and has three shared and ten single bedrooms. Two of the single rooms and one of the double rooms have en-suite facilities. The home has a lounge, dining area and a conservatory. A new extension to the home was built a few years ago and the bedrooms within this prove popular because they lead directly onto the paved courtyard area. However people occupying these rooms would have to have a certain degree of mobility to be able to manoeuvre the step from the rooms to outside. Work has commenced to make these rooms more accessible to all of the service users. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the site visit there were fourteen service users living at the home. The site visit was unannounced and took place on the 21st August 2006. The inspector was at the home for approximately seven hours. The evidence for this report was gathered through talking with nine of the service users, three staff, the manager the home, contact with service users social workers and through returned staff questionnaires and from the returned preinspection questionnaire. The pre-inspection questionnaire had been returned to the Commission before the site visit took place. The service users’ experiences at the home appeared to be very positive saying that all of their needs could be met there and that a homely and friendly environment was provided for them. What the service does well: What has improved since the last inspection? The carpet and lighting in the lounge area of the home has been improved this means that it is a safer environment for the service users to use and makes trips and falls less likely. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 6 Much of the home had been redecorated. Some service users had their bedrooms completely redecorated and new carpets fitted. They said that this made them feel it was ‘more like home’. The home’s statement of purpose and service user guide had been updated to include the details of the homes new manager. This means that the service users or their carers have access to the management if they wish to contact them. All care staff have the right safety vetting completed before they start to work at the home. This means that the service users are protected from possible abuse at the home. Staff receive more regular supervision from the management. This makes sure that they understand the needs of the service users and they receive the support that they require to help the service users do the things that interest them. 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. The summary of this inspection report can be made available in other formats on request. Clover Lodge Care Home DS0000002858.V296192.R02.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 Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made through evidence gathered both during and before the visit to the service. This means that the home provides the opportunity to service users to visit the home before they are admitted there and their needs are assessed to make sure that the home can meet them. EVIDENCE: The home’s Statement of Purpose and service user guides had been updated to include the details of the acting manager. This keeps the service users up to date with any changes that are made to the service. The inspector observed the records held in the home for four of the service users. These all included terms and conditions of their residency at the home and where appropriate the contracts for their care were provided through the funding authority. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 9 The service users had all received an assessment of their needs before they had been admitted in to the home to ensure that their needs could be met there. This included the home’s pre-admission assessment and where appropriate care management assessment of need and care plans. The assessments included recognition of the individual service users’ physical and psychological wellbeing, their hobbies and interests and their religious needs including those in the event of their deaths. Medical histories were also recorded. Direct observations made by the inspector and discussion with service users and their social workers supported the evidence that the home has the capacity to meet the assessed needs of the service users. Service users spoken to by the inspector confirmed that they had been provided with the opportunity to visit the home before they made a decision to move there on a more permanent basis and that this had included trial periods at the home. The home’s policies and procedures support trial periods for up to three months. One service user stated that they had been resident in other homes but Clover Lodge provided much better care and opportunities for them. The home does not provide intermediate care. Clover Lodge Care Home DS0000002858.V296192.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the service users’ needs are met through the services provided through the home or through the professionals based in the community that the home works in partnership with. EVIDENCE: The inspector case tracked four of the service users living at the home. Their care files all included a comprehensive care plan detailing how their needs should be met at the home. The care plans were a combination of the homes care plans and care management care plans. All of the care needs identified in the service users’ assessment of need had been addressed through these care plans. The care plans had all been evaluated on a regular basis to ensure that they were up to date and relevant to the individual service users’ needs. However not all of the care plans had been signed by the service users or their representatives to show their agreement and involvement in the development of them. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 11 The files included clear identification of when individual service users had contact with healthcare professionals that are based in the community. This included GP’s, district and community nurses, opticians and dentists. Service users spoken to by the inspector confirmed that when they have appointments with healthcare professionals they always have the opportunity to see them in private but staff will support them if they need support. All of the staff that administers prescribed medication to service users had received accredited medication training. The majority of the medication records were up to date and had been accurately recorded. However on the day of the inspection one of the MARS sheets had been completed for the following day in error. The inspection was on a Monday and a prescription of Temazepam had been received over the weekend. This prescription had not been recorded in the controlled medication records. All other controlled drugs had been accurately recorded. Direct observation during the site visit and discussions with individual service users supported the evidence that the service users are treated with dignity and respect at all times at the home. The staff were also very aware of the home policies and procedures for upholding service users’ dignity, privacy and respect. Staff were observed by the inspector to knock on service users’ doors and ask permission to be allowed in to their rooms before entering. The care plans seen by the inspector all included the service users’ last wishes in the event of their deaths and this included the religious ceremony that they preferred. No service users had recently died at the home; however, a service user that was severely ill was managed at the home until a more appropriate placement was identified for them. The records showed that throughout this difficult period the home were in constant contact with the service users’ family and the outside professionals based in the community that were involved in their care. Clover Lodge Care Home DS0000002858.V296192.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the service users are provided with daily activities and they have choices in the activities that are provided. EVIDENCE: The routines in the home are very flexible and this included the times for individual service users to rise from and retire to bed. Mealtimes were also observed to be very flexible. Clover Lodge employs a activities co-ordinator who arranges a variety of different activities for the service users at the home and in the community. The activities are usually in an afternoon. This included bingo on the day of the site visit. Some of the other activities offered are flower arranging, Hoopla, indoor bowling, quizzes and music including outside entertainers visiting the home. The home has a monthly Christian service. No service users have any other cultural or religious needs. The manager stated that if a service users with different cultural or religious needs was admitted in to the home them arrangements would be made to meet all of their needs. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 13 The activity co-ordinator is involved in a local activity co-ordinator group that shares ideas and resources for all of their homes. The service users’ care files identify the activities that they have been offered and whether or not they became involved in them. Records of service user meetings identified that they are approached to determine the activities that they would like to become involved in. The care plans also included an assessment of individual service users nutritional needs. The inspector had lunch with several of the service users. They stated that the quality of the food in the home was always very good and that their opinion were sought in relation as to what was included on the home’s menus. A choice of meal was observed to be available at the mealtime and this time was observed to be unrushed and where appropriate support was given to individual service users to completed their meals. The inspector observed the kitchen and found it to be very clean and was well organised. All of the appropriate records were maintained in the kitchen. The stores were well stocked and the homes foods are obtained from the local stores. No special diets were required by any of the service users except low fat and low sugar. The home is only very small and therefore can get all of their foodstuffs from local providers. One of the service users goes to the shops with the provider on a weekly basis to get the food for the home. The service user stated that he ‘enjoys’ doing this and it makes sure the service users get the food that they like. Clover Lodge Care Home DS0000002858.V296192.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the service users are protected from possible abusive situations in the home and they are supported to make any complaints in relation to the services that they receive at Clover Lodge. EVIDENCE: The staff receive protection of vulnerable adults training that is provided through the local authority. The staff that were interviewed by the inspector were aware of adult protection issues and the home’s policies and procedures. There were no adult protection referrals made in relation to the home since the last inspection. The home has a clear complaints policy and procedure. This is made available to service users and visitors in the foyer of the home. There were no recorded complaints made in the home since the last inspection. Service users’ care files showed that they are supported and encouraged to vote at local and national elections. This was a combination of postal votes or service users being transported to polling stations. A service user confirmed to the inspector that they had been taken to a polling station to cast their vote and that they had not been influenced in relation to the outcome. Clover Lodge Care Home DS0000002858.V296192.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is adequate. This means that the environment is generally good however there are some areas that could be improved to support the needs of the service users. EVIDENCE: The home is suitable to meet the needs of the service users. The service users spoken to by the inspector stated that they were very happy with their environment and that they had been given the opportunity to personalise their own rooms with their pictures, ornaments and small items of furniture. The inspector was invited by several service users to see their rooms and this confirmed that they had personalised them to their own tastes and preferences. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 16 Several of the service users’ bedrooms had been redecorated and had new carpets fitted since the last inspection. When service users move out of a bedroom the room is automatically redecorated and new carpets are fitted. The home generally provides a good environment for the service users. The lounge carpet that was identified as requiring attention at the last inspection had been replaced with a new carpet, and the lighting in the same lounge had been improved. This had been simply undertaken by including higher wattage bulbs. The lighting and furniture in the home are domestic in character. One of the proprietors of the home is based on the site and is available to the service users and staff on a daily basis. This has an advantage as any repairs or renewals that are required can be reported directly to him for actioning. The gardens of the home are well maintained and there are plans to develop them further when the portable buildings are removed from the grounds. The proprietors has purchased window restrainers but these have not been fitted yet. Once these have been fitted it will mean that the home is more secure and safe for the service users. The service users are individually assessed for their mobility needs around the home. Up until recently the home did not have a hoist to transfer service users, or to pick them up if they had fallen on the floor. The management recently obtained a hoist on a trial basis and it is envisaged that the home will purchase a hoist in the near future due to the increasing needs of the service users. The bathrooms and toilets are well spaced around the home and are close to the bedroom and communal areas. These areas were well maintained, were very clean and were free of any offensive odours. However bars of soap had been left in one of the bathrooms and this compromises the health and safety of the service users by making them open to infection from contaminated materials. The washing machines are programmable to disinfection and sluicing standards. The home’s renewal plan for the home includes moving the laundry to an outside building. However before this can take place the boilers need to be moved and possibly be updated. The call bell system records showed that it is well maintained and serviced. Service users spoken to by the inspector stated that if they have ever had to use the system the staff were always quick to respond to the call. Observations during the course of the site visit supported this evidence. One service user Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 17 stated that ‘the staff were always very good’ at responding to their calls and needs. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the appropriate safety vetting of the staff is undertaken to ensure the protection of the service users. Supervision of the staff has improved but still needs to be developed further. EVIDENCE: The home benefits from a stable staff group. Unusually since the last inspection there have been four staff that have left the home. Two were for personal reasons, one left following maternity leave and the other returned to undertake further education. The manager of the home confirmed to the inspector that the home uses the Residential forum to calculate the number of hours required for staff to be working in the home. The inspector’s calculations with the staff rotas supported that this was adhered to. Interviews with staff and observation of staff personnel files showed that regular supervision of all of the staff is improving at the home however it is still slightly below the recommended minimum of six formal supervision sessions per year. This means that the management of the home now more clearly understand the needs of the individual members of staff and the staff group as a whole. This includes any training that they may require to meet the needs of the service users. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 19 The staff files showed that all of the appropriate safety vetting is carried out on staff before they commence working with the service users and all of the relevant information to support equal opportunities employment were in position. This is an improvement since the last inspection. Staff at the home are strongly committed to their NVQ training. Four staff have completed the award and the remaining staff are all registered on the award. This equates to 28.6 of the care staff that have a full NVQ2 in care. The home has secured funding for the NVQ training of the staff through the local authority. All new staff at the home undertake appropriate induction training. The manager of the home is looking to develop the homes own induction programme to meet the standards set down by the regulatory authorities. The staff records indicated that the staff receive all of the required mandatory training. The manager would benefit from developing a training matrix that identified when individual members of staff needs to refresh or renew their training. Currently individual staff files include this information but it does not cover the overall training needs of the staff group. Staff interviews and training records supported the evidence that the staff receive in excess of the minimum three days paid training per year and all of the mandatory training is met by the staff group. Staff are also paid to attend training if it is provided on their off duty. Only four out of the fourteen staff questionnaires that were distributed by the Commission were returned by the deadline given. These were all very positive in relation to the services provided at the home and the support that the staff are provided with through the management and through their training programme. Service users spoken to by the inspector spoke very positively in relation to the abilities of the staff working with them. One service user said that ‘there are always plenty of staff’ and ‘they do everything you want them to do for you’. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the management style of the home supports the needs of the service user and staff groups. EVIDENCE: The acting manager of the home has completed the Regulation Managers Award, she also has a HND in Social Care and a BA Honours Degree in Social Sciences. The acting manager has not yet submitted an application to the Commission to be accepted as a fit person and be identified as the registered manager. The home’s standards have improved since the acting manager took up her position there. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 21 The acting manager refreshers her training alongside the staff group and maintains the mandatory training for herself. She has also enrolled on a “training for trainers” course in relation to moving and handling so that the care staffs training can be implemented more frequently in the home itself. The management of the home creates an open positive and inclusive atmosphere. Regular staff and service user meetings are held to identify their views on the delivery and development of the services provided through Clover Lodge. One of the directors of the home is there on a daily basis to offer line management support to the homes manager and they are also widely available to the service users. Returned staff questionnaires and interviews with staff identified that since the acting manager of the home has taken up her post the staff morale has been significantly boosted and the staff feel very well supported. Several staff commented that ‘the manager is very friendly and approachable’ and that they wee very confident with her management abilities. Staff also identified that supervision frequency and the quality of the supervision in the home had improved with the arrival of the new manager. Observation of supervision records in the home supported that the frequency of staff supervision has improved since the last inspection and all staff are close to meeting the recommended minimum of six formal recorded supervision periods per year. This means that they has clearer and more regular guidance on the care plans that they are working with and the have more opportunity to identify their own training needs to support the care of the service users living at the home. The quality assurance and monitoring programme in the home has improved from previous inspections. A series of questionnaires have been sent out to the service users in relation to the services provided at the home. This needs to be extended to other people including health care professionals and commissioners of care at the home. The returned questionnaires then need to be analysed and an action plan should be developed from this and this should then be published. The home is not responsible for any of the service users’ personal finances. This is either undertaken by the service users themselves or through their representatives. Full and accurate records of any of the service users’ monetary transactions at the home were also all up to date. Service user care files identified who was responsible for their personal finances. The home also has a ‘comfort fund’ for the service users. The monies are raised though fund raising events held at the home and they are used to Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 22 purchase presents for the service users on birthdays, Christmas etc and to provide special activities and days out for the service users. Residents meeting records showed how the service users are consulted in relation to how this fund is used. Currently three staff are signatories for the account, and this requires two signatures for each transaction. The manager said that the is considering asking a service user to volunteer to be included as a signatory for the account. All of the records required by regulation were in position; they were up to date and were accurately recorded. Business and financial plans and renewal and refurbishment plans were all in place. The manager was not aware that any service users’ admissions to hospital needed to be reported to the Commission but stated that this would be completed following the site visit. The home had appropriate insurance cover in position and all of the appropriate safety certificates were in position including one for the Electrical Installations and a landlord’s gas safety certificate. The home has all of the required policies and procedures in position and the staff spoken to by the inspector knew how to access them. The policies are reviewed on an annual basis. Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 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 3 18 3 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 2 3 3 Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement Timescale for action 22/08/06 2. OP9 13 (2) 3. OP28 19 The registered person must ensure that all controlled medication received by the home is accurately recorded. The registered person must 22/08/06 ensure that all medication record sheets are accurately recorded to ensure the health and safety of the service users. The registered person must 01/10/06 ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. (The original timescale from the last inspection is still valid) 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 OP21 Good Practice Recommendations The registered person should ensure that infection control policies and procedures are followed throughout all of the home. DS0000002858.V296192.R02.S.doc Version 5.2 Page 25 Clover Lodge Care Home 2. 3. 4. OP31 OP33 OP36 The registered person should ensure that the manager of the home completes an application to the Commission to be accepted as the registered manager of the home The registered person should continue with their development of the homes quality assurance and monitoring system. The registered person should continue with their development of the staff supervision programme to make sure that all staff receive the recommended minimum of six formal recorded supervision periods per year (prerata). Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clover Lodge Care Home DS0000002858.V296192.R02.S.doc Version 5.2 Page 27 - 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!