Inspection on 25/11/05 for Clover Lodge Care Home

This inspection was carried out on 25th 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

Clover Lodge Care Home 06/08/07

Clover Lodge Care Home 21/08/06

Clover Lodge Care Home 28/02/06

Clover Lodge Care Home 24/11/04

Clover Lodge Care Home 01/06/04

Clover Lodge Care Home 04/02/04

Similar services:

Abbey The

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 25th 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 Clover Lodge Care Home DS0000002858.V268579.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. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 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 Mr Gilfred Robert Bebbington Mr Mark Gilfred Bebbington Nathan James Barnard 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.V268579.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2004 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.V268579.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 25 November 2005. The inspection was over eight hours. The information to support this report was gathered through discussions with service users, interviews with management and staff at the home and observation of recorded information in the home including service users assessments of individual care needs and respective care plans. What the service does well: The homes statement of purpose and service user guide gives clear information in relation to the services provided at the home and the staffing availability and structure. All prospective new service users to the home have their needs fully assessed before they are admitted in to the home to make sure that they can be met in the home. The service users are also provided with the opportunity to visit the home and experience a trial period before they decide to move to the home on a more permanent basis. The service users stated to the inspector that they are well cared for and looked after in the home. Individual care plans include comprehensive information in relation to service users needs and the support they require to undertake certain tasks. The service users are provided with a variety of activities in the home and in the community. The service users confirmed that they could choose whether or not to become involved in the individual activities. The meals that are provided are of a very good quality and an inspection of the kitchen found it to be exceptionally clean and tidy and was well organised. Choices are made available to service users at all meal times in the home. The toilets and bathrooms in the home are located close to the communal and individual bedroom areas. Observation of service users bedrooms confirmed that they are supported and encouraged to personalise their rooms to their own tastes and preferences. The tour of the building by the inspector confirmed that it was very clean and tidy and was free of any offensive smells. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 6 Service users stated to the inspector that there are always enough staff working at the home to meet their individual needs and that they were very responsive to the buzzers when they were activated. The management and staff at the home were very positive in their commitment to NVQ and other aspects of mandatory training. The management of the home exceeded the standard for creating an open, inclusive and positive atmosphere. All confidential records held by the home were stored in accordance with the Data Protection Act 1998. 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. Clover Lodge Care Home DS0000002858.V268579.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 Clover Lodge Care Home DS0000002858.V268579.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): 1,3,4 and 5 The home does not provide intermediate care. The service users have their full needs assessed before they are admitted in to the home and are provided with choice in how their care will be delivered. EVIDENCE: The homes statement of purpose and service users guides had recently been updated. They included all of the required information including the manager’s details, the proprietor’s details, the homes organisational structure, the accommodation provided, fees, complaints policy and the admission policy. There are currently fifteen-service user living at the home. The inspector observed three case file records in relation to the current service users. These all included a full assessment of the service users needs prior to them moving in to the home. The service users spoken to by the inspector confirmed that they had their needs assessed before they came to live at the home and Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 9 they were able to visit the home before they decided to move in there on a more permanent basis. The assessments were a combination of the homes pre-admission assessments and assessments provided through the care management teams that had arranged placements for service users at the home. The assessments included the physical and healthcare needs of the service users including moving and handling plans, nutritional needs, pressure area and waterlow assessments. The assessments also included information in relation to the service users finances and if they were responsible for their own, or a representative looked after their finances. The records kept by the home, the inspectors observations and discussions with service users confirmed that the home has the capacity to meet the assessed needs of the service users. Clover Lodge Care Home DS0000002858.V268579.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): 7,8,9 and 10 The health and personal care needs of the service users are well met at the home. EVIDENCE: The inspector observed the care plans for three service users living at the home. These all included thorough details of how individual needs must be met. Most of the care plans had been singed in agreement by the service users or their representatives. The care plans are broken down in to different sections including ‘The help I need’, ‘The help I would like’ and ‘Who would I like to help me’. The individual care plans also included the name of the service users keyworker the aims of the care plan, the goals, and the risk factors involved when delivering their care. The care plans identified how individual health and social care needs would be met and where appropriate identified the healthcare professionals that were supporting individual service users needs in the home. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 11 Clear records were made in relation to service users contact with healthcare professionals. The service users stated to the inspector that when they were seen by healthcare professionals at the home that they were always seen in private. Pressure areas for individual service users were well recorded and maintained with support form the district nursing service Staff administering prescribed medication at the home all receive accredited medication training provided through a local college as a distance learning course. The local pharmacy that provides the medication to the home had recently visited to home to observe the recording and storage of medication in the home. The inspector observed medication being administered to the service users at the home and appropriate legislation and good practice guidelines were followed. However, there were two discrepancies in the recording of administered medication at the home. One prescribed drug in a nomad pack had been administered even though the MARS sheet identified that the medication had been discontinued by the GP. There was also a minor discrepancy in the recording of the controlled drugs held by the home. This was in the totalling up of the remaining drugs and an error in the subtraction. Direct observations by the inspector confirmed that the service users privacy, dignity and respect are upheld at all times at the home. Preferred terms of address are identified in individual service users care plans. Clover Lodge Care Home DS0000002858.V268579.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 and 15 The service users are provided with choice in how they lead their daily lives at the home and stimulating activities are made available to them. EVIDENCE: Service users stated to the inspector that their have a choice in their daily activities at the home and can choose whether or not to become involved in any activities that are promoted both at the home and in the community. The home employs a part-time activity co-ordinator. She works every day Monday to Friday. The activity co-ordinator is also involved in an activity coordination group that meets locally and raises monies to provide activities for individual care homes. The homes ongoing activities included pub lunches, church visits to the home every month, individual 1-1 visits to the local community, card games and bingo. For the Christmas period the service users have been asked to turn on the Christmas lights at a local event, and the Salvation Army and local Church have arranged to visit the home to entertain the service users. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 13 There is only one dining area in the home but the service users stated that if they want they can have their meals in their own rooms or even the communal areas of the home. The service users confirmed that they are provided with choice throughout their daily lives at the home. The inspector ate with a group of service users and the meal provided was very tasty and was well presented. The service users stated that the meals at the home were always of a very good standard. A choice of meal was identified at all meal times in the home. The inspector also looked around the kitchen in the home. This was found to be exceptionally clean and there were plentiful supplies in stock. There were no special diets identified for service users at he home except low fat and low sugar diets. No diets were required in relation to individual service users religious or cultural needs. Clover Lodge Care Home DS0000002858.V268579.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): 16 and 18 The service users are provided with a safe environment and there is a clear complaints procedure that the can use if required. EVIDENCE: Since the homes last inspection there has only been one recorded complaint in relation to the home. The complaint was in relation to the homes kitchen and the cleanliness of the area. The complaint was not upheld. Service users spoken to by the inspector understood how to make a complaint in relation to the care they received if they wished to. Staff interviewed by the inspector were aware of the needs on vulnerable adults and what should constitute a referral for a vulnerable person. The homes policy and procedure for the protection of vulnerable adults needs to be updated. Currently the policy states that the manager of the home would start the investigation in to any alleged abuse. The policy should state that this must be reported to the appropriate authorities who would then instigate an investigation. The manager of the home was well aware of these requirements and confirmed that this was the action that the home would adhere to. Clover Lodge Care Home DS0000002858.V268579.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): 19,20,21,23,25 and26 The environment of the home is well presented and provides a homely atmosphere for the service users. EVIDENCE: Many of the carpets in the home had recently been replaced and the call system had been extended to cover the conservatory. The lounge carpet is in need of repair or replacement as it has begun to wear and fray near to the entrance door. Although the kitchen is very clean the cupboards and work surface are in needs of attention or replacement. The home has one dining area and one communal area. The lighting and furniture in both these areas were domestic in character. The dining room would benefit from some additional light as it is quite dimly lit and there is a refurbishment plan that includes renewing the seating in the communal area. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 16 The service users confirmed that they could choose to uses the communal areas or were free to utilise their own space in their individual rooms. Three of the bedrooms in the home include en-suite facilities. Additionally there are three separate toilets and toilets included in the bathrooms at the home. These are all well spaced out through the home and are close to the service users personal rooms. A tour of the premises by the inspector confirmed that service users have been able to personalise their individual rooms to their own tastes and preferences. This included small items of service users personal furniture, pictures and ornaments. The tour of the building also identified that it was very clean and tidy and was free of any offensive smells. The hot water pipes in the home have not been provided with low temperature surfaces. This could cause contact injuries for service users. The home also needs to begin random monthly checks on the temperature of the water at the hot water outlets. There are no sluice facilities in the home however the homes washing machines are programmable to disinfection and sluicing standards. The laundry is very compact but a new laundry is currently under construction and is almost completed. Clover Lodge Care Home DS0000002858.V268579.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): 27,28,29 and 30 Staff levels at the home are appropriate to meet the needs of the service users. EVIDENCE: The service users confirmed to the inspector that there are always appropriate numbers of staff available at the home to meet their individual needs. They also confirmed that the staff were very helpful towards them and that they were always polite and sociable. The service users that spoke to the inspector were aware of who their keyworker was at the home and what this meant. There are no staff under eighteen that provide personal care to the service users and nobody under twenty one is ever left responsible for the building. Staff meetings are held on a monthly basis at the home. The records of these meetings identified that they are involved in the planning and development of services provided at the home. New staff employed by the home undertake induction and foundation training to TOPP’s requirements. This was confirmed to the inspector through the inspector’s interviews with staff. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 18 The staff and management of the home are committed to the homes requirements for NVQ training. Currently four staff have achieved a full NVQ 2 award in care (20 ), another member of staff is working towards the award and a further five staff have been given the opportunity to enrol on the award. The inspector was unable to verify the homes recruitment procedures, as the staff personnel files were not available for inspection. The manager of the home is currently moving in to a new office and all of this information was boxed and was in transit. Staff also confirmed to the inspector that they receive in excess of the required three days paid training per year. The home employs additional kitchen and domestic staff to the care staff at the home. This means that the care staff can concentrate all of their time on the needs of the service users. The activity co-ordinator is employed for ten hours a week for two hours a day Clover Lodge Care Home DS0000002858.V268579.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): 31,32,35,37 and 38 The management of the home encourages a homely atmosphere for the service users and is always available for the service users to access. EVIDENCE: Much of the information required to support the management and administration standards were not available at the inspection, as the manager had packed all of the information to be transferred to their new office. The manager of the home has completed NBOSH health and safety training for trainers in moving and handling and has recently completed an NVQ 4 in care. The manager also confirmed to the inspector that they are currently studying for a BA Honours degree in Social Science. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 20 Service users spoken to by the inspector and interviews with staff working at the home confirmed that the management of the home was open, positive and inclusive. Standard 32 NMS was exceeded in relation to the openness and availability of the management. The home has a quality assurance and monitoring system but this was not available at the inspection. The staff personnel records were also not available for inspection. The manager stated to the inspector that the home has a current business and financial plan but this was not available on the day of the inspection as well of the other information due to it being prepared to be transferred to the manager’s new office. Service users are responsible for their own finances were appropriate. Where service users are not able to care for their own finances have this identified in their individual care plans. The inspector looked at the pocket money accounts of three service users. The records were all up to date and were accurately recorded. Staff at the home and the manager confirmed to the inspector that they receive regular formal recorded supervision at the home that meets the minimum standard. However the inspector was unable to support this standard, as the records were not available to see. All of the information required by regulation for the protection of service users with exception to the staff records were all available and were up to date and were accurately recorded. The records were all held in accordance with the Data Protection Act 1998. A tour of the building by the inspector confirmed that the home was taking every reasonable step to ensure the health, safety and welfare of the service users. The certificates to support some of the health and safety issues including safe electrical and gas systems were not available to support the standard due to being packed in transit. Clover Lodge Care Home DS0000002858.V268579.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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 2 2 3 3 X 3 X 2 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 X X 3 X 3 X Clover Lodge Care Home DS0000002858.V268579.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 OP9 Regulation 12 and 19 Requirement The registered person must ensure that all staff administering medication to the service users in the home have received accredited medication training and all controlled medication is appropriately stored and recorded. Timescale for action 26/11/05 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 OP18 Good Practice Recommendations The registered person must ensure that the homes policies and procedures are updated to include that the manager of the home must not instigate any investigation in to suspected abuse and must report the alleged offence to the appropriate authority who will then investigate the concerns. The registered person must ensure that the carpet in the lounge is repaired or replaced to ensure the health and safety of the service users. The registered person must ensure that all of the exposed DS0000002858.V268579.R01.S.doc Version 5.0 Page 23 2 3 OP19 OP25 Clover Lodge Care Home 4 5 OP28 OP31 hot water pipes in the home are provided with low temperature surfaces to avoid contact injury to the service users. The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent by 31st December 2005. The registered person must ensure that the manager has achieved the Registered Managers award or equivalent by 31st December 2005. Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Clover Lodge Care Home DS0000002858.V268579.R01.S.doc Version 5.0 Page 25 - 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!