CQC report explained · a residential care home
What the CQC found at Clova House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2019
Rated Requires Improvement; inspectors found kind and responsive care, but concerns about staffing, medicines, consent and the home’s condition.
Inspectors made an unannounced visit on 11 September 2019. They spoke with people living in the home, relatives, staff and managers. They also observed care and checked care plans, medicine records, staff files and management records.
People generally felt safe and were treated kindly and with respect. Staff understood people’s needs, food was good, healthcare advice was followed, and people’s routines and relationships were supported.
However, there were sometimes too few staff to respond promptly. Medicine records were not always complete. Some mental capacity and liberty safeguard checks were out of date or missing. The home was not consistently clean and needed renovation. Staff recruitment and training records also had gaps.
The overall rating was Requires Improvement. Safe and Effective were rated Requires Improvement. Caring, Responsive and Well-led were rated Good. Safe had stayed at Requires Improvement, while Effective had fallen from Good at the previous inspection.
Kind and respectful care
People experienced warm and compassionate interactions. Staff respected privacy, dignity and personal choice.
“Staff were caring and we observed positive interactions between people and staff.” from the report
Good understanding of people
Staff knew people’s routines, preferences and communication needs. This helped people follow their usual routines and make choices.
“Staff had good knowledge of people's preferences and routines.” from the report
Food and mealtimes
People spoke positively about the food. Staff provided support with eating in a caring and dignified way.
“People received a balanced diet. People told us that they enjoyed the quality of the food.” from the report
Following professional advice
Advice from health and social care professionals was recorded and followed. This included advice about food texture and specialist equipment.
“Where professionals had given advice, this was clearly documented and staff were aware.” from the report
Staffing at night
seriousThere were sometimes only two staff overnight, even though three people could need two staff at the same time. This could leave nobody available to respond to others and delay help with toileting or bedtime.
“While the two staff were supporting these people, there would be no other staff available to respond to people at night.” from the report
Medicine records
seriousStaff did not always sign clearly when medicines had been given. Guidance and records for medicines given when needed were also not always clear.
“Staff did not always clearly sign records to show that medicine had been given, this would make it difficult to review which medicines had been given and by whom.” from the report
Consent and legal safeguards
seriousSome liberty safeguard assessments had expired, and mental capacity assessments relating to CCTV had not been completed. This created a risk that decisions would not be made lawfully or in people’s best interests.
“These policies and systems put people at risk of not being supported in the least restrictive way possible and in their best interests.” from the report
Cleanliness and repairs
needs fixingThe home was not clean throughout and needed renovation. Dirt, rust, stained carpets, exposed woodwork and taped-down carpet were found.
“The service was not clean throughout, for example there was dirt and rust underneath a communal bath seat and carpets were stained.” from the report
Recruitment and training
needs fixingRecruitment checks and references were not always complete. Some staff had gaps in training, including food hygiene, mental capacity and dementia training.
“Staff were not always safely recruited.” from the report
Activity records
minorThe home said activities took place most days, but it did not keep clear records. Inspectors could not therefore assess the full range of activities.
“There were not clear records kept on this, so we could not assess the type of activities offered.” from the report
- 01How many staff are on each shift now, especially overnight, and how do you make sure people are not left waiting for help?
- 02How are medicine administration records and guidance for medicines given when needed checked now?
- 03Have all mental capacity assessments and liberty safeguard applications been reviewed and kept up to date?
- 04Which cleaning, lighting and renovation works identified in the inspection have been completed?
- 05How do you record and review activities so that each person has suitable opportunities to take part?
This was a planned, unannounced inspection of all five key questions; Safe remained Requires Improvement, Effective fell from Good, and Caring, Responsive and Well-led remained Good. This explanation was written from the published report of 1 November 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2017
Clova House Residential Care Home was rated Good overall, but inspectors found that medicines records, infection control and some safety systems needed improvement.
The inspection was unannounced and took place on 24 January 2017. It was the first inspection since the provider registered in June 2016. Inspectors spoke with people, a relative, staff, the registered manager and the provider. They observed care and reviewed care, medicines, recruitment, training and quality records.
People said they felt safe and there were enough staff. Staff understood people's risks and safeguarding responsibilities. However, medicines records were not always completed correctly, medicine storage checks were not consistent, and the laundry arrangements could increase the risk of infection. Mental capacity assessments and quality checks also needed further development.
The home was rated Good for Effective, Caring, Responsive and Well-led. Safe was rated Requires Improvement, so the overall Good rating should be read alongside the specific safety concerns. The provider and manager said they would make improvements, including to medicines, laundry, the environment and quality monitoring.
Staffing and risk management
Inspectors found enough staff and saw that risks such as falls and health conditions were assessed and acted on.
“There were sufficient number of staff deployed within the service to keep people safe.” from the report
Kind and respectful care
Staff knew people well, listened to their choices and protected their privacy and dignity.
“Staff had developed positive, caring relationships with people. People were treated with dignity and respect and their right to privacy was upheld.” from the report
Personalised support
Care plans included people's likes, dislikes and routines. Staff responded when people's needs changed.
“This meant that people received care that was personalised and met their needs.” from the report
Food and healthcare
People enjoyed the meals and could choose when and where to eat. Staff supported nutrition and contacted health professionals when needed.
“People were supported to have sufficient to eat and drink and maintain their health and well-being.” from the report
Leadership
People and staff were positive about the manager's support and ability to listen. The provider and manager had an improvement plan.
“The registered manager had demonstrated good leadership. People and staff were able to share their views and influence how the service was run.” from the report
Medicine records and storage
seriousSome medicine administration records were not signed, and controlled drug records did not always have the required two signatures. Storage temperatures and opening dates for some medicines were not consistently checked or recorded.
“Records to show people had received their medicines were not always properly recorded.” from the report
Laundry and infection control
seriousThe laundry room was unfinished and clean laundry was stored above soiled laundry. Some machine doors were faulty, which could increase the risk of infection.
“Clean laundry was stored above soiled laundry and several of the machines had doors that were taped up which indicated the doors were faulty.” from the report
Safeguarding procedure
seriousAt the inspection, the provider did not have an in-home safeguarding policy and procedure. A procedure was provided after the visit.
“However, the provider did not have a policy or procedure for safeguarding people within the service.” from the report
Mental capacity records
needs fixingCapacity assessments described day-to-day support but were not linked to specific decisions at specific times, such as healthcare treatment.
“Although assessments detailed the level of support people needed to make decisions on a day-to-day basis, they did not relate to any specific decisions made at any specified time.” from the report
Environment and activities
minorSome bathrooms, toilets, lighting, signs and floor and wall coverings needed improvement for people living with dementia. The manager was also developing more one-to-one activity support.
“The premises required further work to support the needs of people living with dementia.” from the report
- 01Have all medicine administration records, controlled drug records and medicine storage temperature checks been completed correctly since the inspection?
- 02Has the laundry room been completed, with clean and soiled laundry kept separate and faulty machines repaired?
- 03How are mental capacity assessments now linked to specific decisions, such as healthcare treatment?
- 04What regular audits and spot checks are now carried out, and how are the results recorded and acted on?
- 05What activities are now available for people who need one-to-one support, particularly those living with dementia?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the service. This explanation was written from the published report of 22 March 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Clova House Residential Care Home
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- November 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Clova House Residential Care Home →
- March 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Clova House Residential Care Home →
- June 2016
Registered with the Care Quality Commission on 23 June 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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