Archived: Clova House Residential Care Home

Updated 4 February 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We undertook an unannounced focused inspection on Clova House on 26 November 2015. This inspection was to check that improvements after our comprehensive inspection on 4 February 2015 had been made.

We inspected the service against three of the five key questions we ask about services: is the service 'safe', is the service 'effective' and is the service 'well-led'. This was because the service required improvements to meet the legal requirements.

The inspection team consisted of one inspector.

We spoke with four people who used the service, two staff members, the deputy manager and a visiting training professional. We reviewed a range of records about people's care and how the service was managed. This included three peoples' care plans, two staff files and records in relation to the management of the service. We observed care and support in communal areas. We looked at the environment including bedrooms, bathrooms and communal areas.

Prior to the inspection we reviewed the information we had about the provider. This included previous inspection reports, information received and statutory notifications. A notification is information about important events which the provider is required to send us by law.

Updated 4 February 2016

This inspection was carried out on 26 November 2015 and was unannounced. We last inspected Clova House on 4 February 2015. We found that that the service was meeting the requirements of the regulations, but we made recommendations that they further improve in the areas of staffing, managing risks and governance. We carried out this focused inspection to follow up on these areas. You can read the report from our last comprehensive inspection by selecting 'all reports' link for Clova House Residential Care Home on our website at www.cqc.org.uk

At this inspection we found that improvements had been made to staffing and managing risks. However although people's day to day capacity had been assessed and recorded within some care plans, there was no evidence that people had been supported to make significant decisions about their care or well-being, such as changes to the way their care is provided and the level of supervision they required each day.

We were told that the provider had not submitted any DoLS applications to a supervisory body although some of the people living in the home were under constant staff supervision and may not have capacity to make decisions in their best interests. This meant that people living in the service may have decisions made for them that may not be in their best interests and could have their liberty deprived This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Clova House provides accommodation for up to 20 older people. At the time of inspection there were 16 people using the service. The service is located in a residential area of Shelton Lock. Clova House is a converted domestic dwelling and provides accommodation on two floors and is served by both a passenger lift and a stair lift.

The provider is also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were sufficient numbers of staff deployed within the service to meet people's needs. The provider had implemented a revised management structure since our last inspection to improve administration and support for staff. Staff told us that they felt supported by the new deputy manager.

The service kept people safe and effectively managed risks to people using the service. Records showed that risks to people's health and well-being had been identified, assessed and managed in an appropriate way. People we spoke with were happy with the care that they received and told us that they felt safe in the service.

People who used the service told us that staff were kind and caring. We saw that staff treated people with dignity and respect.

Staff had attended a variety of role specific training. We observed that staff were not always consistent in responding to the needs of people living with dementia. Some staff told us that they struggled to understand the right approach to support people living with dementia. We raised this with the deputy manager and recommended that the service finds out more about training for staff, based on current best practice, in relation to the specialist needs of people living with dementia.

There were procedures for monitoring and assessing the quality of the service. However our findings showed that the provider's approach to quality assurance was fragmented and we found that some audit processes were out of date or ineffective. There were further improvements required to quality assurance and monitoring to ensure that processes were robust and effective.

You can see what action we told the provider to take at the back of the full version of the report.