Inspection on 16/08/05 for Cleeve Court

This inspection was carried out on 16th August 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

Cleeve Court 30/11/06

Cleeve Court 27/01/06

Cleeve Court 07/09/04

Cleeve Court 14/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Cleeve Court Cleeve North Somerset BS49 4PF Lead Inspector Alison Murray Announced 16 August, 2005 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 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. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cleeve Court Address Cleeve, North Somerset, BS49 4PF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 876494 01934 830626 Cleeve Rest Limited Mrs Linda Susan Gill Care home with nursing 29 Category(ies) of Old age (29) registration, with number of places Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 29 persons aged 50 years and over requiring nursing care. 2. Staffing Notice dated 08/11/1999 applies 3. Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 7 September, 2004 Brief Description of the Service: Cleeve Court provides nursing care for up to 29 older people. The home is situated in the village of Cleeve, and can be accessed by car or bus. This would be required for easy access to local shops and social venues. The home is a converted older property, set within large, attractive grounds. It offers 22 single and 4 double rooms on three floors. A total of 9 rooms have en suite facilities. There is a lift for residents to all floors. Cleeve Rest Limited owns Cleeve Court. Mr Paul Bliss is the responsible individual for the company. He owns a number of care homes in the area. Mrs Gill was appointed as the home manager in February 2004. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very positive announced inspection. A total of 8.5 hours were spent in the home. Although a wide range of records were reviewed, the main focus of the inspection was the day-to-day experience of the residents. During the inspection, a total of 13 of the 26 residents were consulted individually. The majority of the remaining residents chatted with the inspector during the course of the day. Comment cards were received from three residents, and four visitors were asked about their impression of the home. Staff were not formally interviewed, but observed as they went about their work. What the service does well: What has improved since the last inspection? Since the last inspection, the staff records have improved significantly. They now demonstrate a robust recruitment procedure. This ensures that suitable staff are employed to work in the home. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 6 The ongoing programme of maintenance and redecoration continues to improve the standard of accommodation offered at Cleeve Court. Work has been completed to a high standard, and is in keeping with the character of the building. 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. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 standard(s) 3, 4 and 5. Cleeve Court does not provide intermediate care, so standard 6 is not applicable. Residents’ needs are effectively assessed before they are admitted to the home. Staff are clear about the range of needs they can and cannot meet. Residents and their families are given good information about the services offered at Cleeve Court. EVIDENCE: Mrs Gill said that she always visits prospective residents before their admission to Cleeve Court. She uses this opportunity to assess their needs, and tell them about the home. Care records reviewed contained evidence of a comprehensive pre admission assessment. Recently admitted residents confirmed that they were given good information about the range of services offered at the home. One lady said that as she was in hospital, a relative had visited the home to meet the staff and look at various rooms. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 9 Mrs Gill and her staff were clear about the range of needs that could be met at the home. During the inspection, they liaised with a consultant to ensure that they were fully equipped to meet the new needs of a resident, following a stay in hospital. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 and 11 The standard of care documentation is good. Residents’ health and personal care needs are well met. There is a friendly atmosphere in the home, with a good rapport between residents and staff. EVIDENCE: The standard of care documentation was good. Care plans were written for each area of identified need. They provided staff with clear guidance to meet residents’ needs. This guidance was based on current good practice, and demonstrated the involvement of other health professionals. Comments received from a local GP confirmed that the staff work well with the local surgeries. Staff showed a sound awareness of residents’ needs. Residents felt comfortable that staff had the knowledge and skills to look after them. One person praised the efforts of the staff in ‘sorting’ continence problems. Another said that he had recently needed to attend a hospital appointment. He was very grateful that a member of staff had accompanied him, and was there to Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 11 ‘remember all the things the doctor told me’. She was then able to explain these to the gentleman’s family. Many residents were consulted individually, and others observed in the communal areas of the home. All were neatly dressed, and attention had been paid to their hair and nail care. A number of residents were being nursed in bed. They looked comfortable, and had been provided with suitable pressure relief equipment. One lady had specialist communication needs. She had been given a most effective communication device, and was happy to chat to the inspector. A resident was due to be readmitted to Cleeve Court from hospital. It was clear that this person had made an active choice to return to the home for terminal care. Staff discussed the care that would be required with the hospital consultant. Together they planned how to support the resident and his family during the final stages of illness. There was a calm, relaxed atmosphere in the home. The residents said that the staff were ‘lovely’, with several naming specific favourites. They gave numerous examples of staff members going out of their way to be helpful. The deputy manager takes responsibility for the ordering and storage of medication. She has recently completed a course in the safe management of medications. The medication administration records were well maintained, and drugs securely stored. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 The programme of planned and informal activities offered at Cleeve Court meets the needs and expectations of the residents. Family and friends are made welcome. Residents enjoy the meals provided. EVIDENCE: An Occupational therapist has recently been appointed to work in the home for 6 hours a week. Mrs Gill said that she was gradually getting to know the residents. She was prioritising one to one work with individual residents, as well as offering a range of complimentary therapies. A number of the residents commented that she seemed ‘very good’. Several emphasised that they had no wish to join in any form of organised activity. One person said ‘we are all very different, so it would be difficult to find one activity which would suit us all’. It was clear that residents were able to choose how to spend their day. Those in the communal areas watched TV, or listened to music. Residents in their rooms were busy with puzzle books, knitting or reading newspapers. Staff were observed to sit and chat with residents. One of the current residents used to work with animals. Mrs Gill said that they had noticed that he was missing the opportunity to handle animals, so staff Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 13 had brought their own pets in to visit. The recent purchase of a fish tank has generated a lot of interest. Staff and residents were looking forward to a ‘cream tea’ afternoon the following weekend. Several residents said that their families were helping to organise the event, by providing musical entertainment or running stalls. Photographs of other events were displayed in the entrance hall. These included Easter, Christmas and Halloween parties. Conversations with staff, residents and relatives confirmed that visitors are always made welcome. A number of residents commented that they appreciated the regular visits from local clergy. The meal served during the inspection looked and smelt appetising. Staff were on hand to offer discreet assistance where required. Conversations with residents and comment cards received as part of the inspection process confirmed that the food provided in the home is of a consistently good standard. A number of the residents require special diets. The cook explained how she tries to tempt their appetite with favourite dishes. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 standard(s) 16 and 18 The complaint procedure in the home is satisfactory. Staff demonstrate a good awareness of adult protection issues. EVIDENCE: There are comprehensive policies and procedures in place. Residents and relatives all confirmed that they knew how to use these procedures if the need should arise. Several commented that they felt comfortable raising informal concerns with Mrs Gill. Staff have received extensive training in adult protection issues. They demonstrated a good awareness of these. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 Cleeve offers good all round accommodation. The standard of housekeeping is commendable. EVIDENCE: Since the last inspection, the maintenance person has redecorated a number of areas. This work has been completed to a high standard. All rooms are attractively decorated, in keeping with the character of the building. All the residents consulted said that they liked their room. Since the last inspection, several have moved to a different room. One person said ‘I’ve had my eye on this room, since I first came into the home. When it became available, staff asked me if I would like to move. I have such a wonderful view from my window, and can see everyone coming and going’. The standard of housekeeping is particularly good. All areas of the home were extremely clean and tidy. Residents said that they were very happy with the way their rooms were cleaned. The housekeeper and her staff demonstrated a commendable pride in their work. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 16 Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Robust recruitment procedures help to ensure suitable staff are employed to work in the home. A very comprehensive training programme equips staff with the skills and knowledge to meet the needs of the residents. EVIDENCE: Residents said that they felt that the staffing levels were appropriate. One person said, ‘when I press my buzzer, they answer nice and quickly’. During the inspection, call bells were answered promptly. Staff commented that they were kept busy, but still had time for a chat and a joke with residents. The records kept in relation to three recently appointed staff were inspected. These demonstrated a thorough recruitment procedure. Two written references and a PoVA First check had been obtained before they started work in the home. Mr Bliss had contacted the Home Office to check the immigration status of an overseas nurse before confirming her appointment. A total of 6 of the care staff (33 ) have obtained at least level 2 NVQ. Mrs Gill said that others planned to enrol on a course in the coming months. All staff are offered very good training and development opportunities. Mrs Gill has prioritised courses that were relevant to the needs of the current residents. Staff have recently attended training on adult protection, health and safety, safe handling of medicines, venepuncture and nutrition. Staff have access to a wide range of learning materials within the home. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The home is effectively and efficiently managed. Systems are in place to enable staff, residents and visitors to comment on the way the home is run. EVIDENCE: Mrs Gill has nearly completed her level 4 NVQ in management. There was much evidence to confirm Cleeve Court is effectively managed. There are clear lines of accountability between Mr Bliss and Mrs Gill. Staff praised their management style. They said that they felt valued, and were well supported. Minutes of staff meetings confirmed an open culture in which staff felt able to comment on the way in which the home was run. Mrs Gill does not hold formal meetings for residents. Despite this is was clear from conversations with residents and their relatives that they feel fully involved in the day-to-day running of the home. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 19 Mrs Gill and Mr Bliss have developed comprehensive quality monitoring and quality assurance systems. Mr Bliss regularly visits, and talks to the residents about their experiences in the home. He documents his findings in a monthly report. Mrs Gill carries out satisfaction surveys, and monitors the care and medication documentation. All the records inspected were well maintained and stored appropriately. The responsibility for health and safety issues is shared between Mrs Gill, Mrs Knight, her deputy, and the maintenance person. Their records confirmed that all the necessary checks, tests and drills had been carried out. Staff on duty demonstrated a very good awareness of health and safety matters. Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 3 x x 3 3 3 Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 21 No 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 Cleeve Court D53 -D02 S20274 Cleeve Court V232903 160805 Stage 4.doc Version 1.40 Page 23 - 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!