Inspection on 30/11/06 for Cleeve Court

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 27/01/06

Cleeve Court 16/08/05

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 Barbara Ludlow Unannounced Inspection 30th November 2006 10:20 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 Cleeve Court DS0000020274.V319290.R01.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. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Court Address Cleeve North Somerset BS49 4PF 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) 01934 876494 01275 464470 Cleeve Rest Limited Mrs Linda Susan Gill Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 29 persons aged 50 years and over requiring nursing care Staffing Notice dated 08/11/1999 applies Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 27th January 2006 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. The fee range is from £494.58 to £650.00. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very positive inspection with ‘excellent’ judgements for the outcome groups. This unannounced inspection commenced on 30/11/06 and was undertaken by B Ludlow for CSCI. The inspection was well received and the acting deputy manager was available throughout day one to assist with the inspection process. Mrs P.Martin, representing the company, came to the home to support the inspection process. It was agreed that the visit would be completed the next day to allow the homes Manager to contribute towards this key standards inspection process. There were twenty-two service users in residence and one person was in hospital. There was a full complement of staff on duty. Staff from all departments, catering, domestic, and care were observed and spoken with during the day. Service users were seen and spoken with during the day in the communal areas of the home and some in private in their rooms. Lunchtime in the dining room was observed. A tour of the premises was made, communal rooms were seen and bedrooms were sampled. Medications management was discussed with the acting deputy manager and the administration records and storage was seen. Care plans and care records were sampled. Three relatives were spoken with and their views of the service and the care of their relatives were shared with the inspector. Inspection feedback was given to Mrs Martin and the deputy manager during day one. Day two commenced at 2.45pm, Registered Manager Mrs L.Gill and Registered Provider Mr P. Bliss were present throughout the visit. Service users seen in the dining room were busy with a craft session, producing Christmas cards. Discussions were held regarding all aspects of the management and the development of the care home service at Cleeve Court. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 6 Hot surfaces were reviewed from day one and records for maintenance were inspected. Staff recruitment files were sampled and contacts were made available. Feedback was given to Mrs Gill and Mr Bliss. The inspector would like to thank the service users and the relatives who kindly contributed with their views on the quality of care and service given at Cleeve Court. The management and all staff at the home are also thanked for their time and contribution to the inspection process. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk What the service does well: What has improved since the last inspection? The complaints procedure has been addressed and the manager has devised an innovative system. Information about how to raise a concern or make a Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 7 complaint or compliment along with CSCI information, envelopes and a pen are now provided in each bedroom. The manager stated that service users have responded ‘to test the system’. It is hoped that this will be a comfortable and easy way for any concerns to be raised with the home’s management. The home’s acting deputy manager has made a lot of effort to refresh nursing practices and update wound care management at the home. Information has been made available for the staff and posters of wound care information are displayed in the treatment room. Care plans demonstrated detailed appropriate health and nursing care planning and interventions. Pressure relieving equipment in use is now documented. 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. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 8 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 Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5, NMS 6does not apply. Quality in this outcome area is excellent. There is a good level of information and support from the home for prospective and new service users to ensure a smooth transition into care that can meet their assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cleeve Court has a statement of purpose and a service users guide. A recent draft copy of the home’s statement of purpose has been seen at CSCI, a final draft will be required for the CSCI record. There is a visitor’s book in the entrance hall and visitors are encouraged to sign in at every visit. This practice was undertaken by all visitors to the home Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 10 during this inspection. The home has an open door policy and visitors upon signing in are welcome to come into the home. Other useful information is displayed in the entrance hall, this includes the homes philosophy of care, complaints information and information about CSCI. Service users visitors were seen; one offered a useful insight to the home’s admission process. The Manager, Mrs Gill, had carried out a pre admission assessment visit. Mrs Gill received praise for the help and consideration she had given the prospective service user and the family at this time. The family stated that the move had been supported with care and they had felt to be included and involved with the reviewing processes post admission. This was evidence of a good admission process. The documentation for pre admission assessment was seen in the care plans sampled at this inspection. Detailed written records of the assessment processes were held. The registered manager has developed a form for families to complete as part of the pre admission assessment process; this covers the activities of daily living and a clothing inventory. This had been designed to capture relevant information about the less well service user from their main carer / family. The manager stated that this is proving very helpful. The service users who were asked had received help from their families to ‘find a place’; these service users were not able to confirm that they had received a copy of their contract or terms and conditions. The contracts / terms and conditions of residence were seen and these were sampled on day two. The contracts were clear about the fee payable and the room number. These were signed by the relevant parties. The fees vary depending upon the size of the room to be taken. The Registered Nurse Care Contribution (RNCC) is paid directly to the home, the low band money is refunded, and medium and high band monies are kept towards the cost of nursing care. Extras included, hairdressing, newspapers and toiletries, these are charged at cost. The manager stated that the RNCC, Free Nursing Care assessment form is given out to service users and their families, on behalf of North Somerset Primary Care Trust, for them to complete if they wish to be assessed for their eligibility for this payment towards the cost of their care. All written feedback to CSCI was positive regarding the level of information received before entering the home. All respondents stated that they had received a contract / terms and conditions of residence. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 11 All service users seen at this inspection were appropriately placed and the care home and staff were able to meet their assessed needs. Families and service users confirmed this very positively when spoken with. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10,11 Quality in this outcome area is excellent. The health and personal care delivered at Cleeve Court is of an excellent standard. Service users feel they receive very good care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector spent a good part of the first day with service users and their relatives to gain an insight into daily life at Cleeve Court. The care plans were sampled and assessed for relevant content. The care plans were stored on the nurse’s desk in the main foyer. This was not the most suitable place for them, as the area is not always occupied by staff. Mr Bliss agreed to have these documents removed to more appropriate and Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 13 locked storage, as soon as possible. The new storage had been determined and agreed by day two of this inspection. The care plans clearly recorded all relevant contact information for both family and health care professionals. The Waterlow pressure sore risk assessment and nutritional risk assessments had been completed; action had been taken to meet pressure relieving equipment needs. Regular weights were recorded and BMI (Basal Metabolic Index) calculated, special diets and referral to the dietician if appropriate is made where there is an identified nutritional risk. There is a GP visit to the home each week by one of two G.P’s. The home reports good relationships with the Primary Care Trust and professionals allied to health care. A visit by the Community Physiotherapist was made during the inspection to attend to and advise staff on the aftercare of a person who came in from hospital and requires rehabilitative care. The storage and management of medications was inspected. The visiting G.Ps had recently spent time at the home reviewing each persons medication. There had also been an inspection by the supplying pharmacy, of the systems and staff practice. At this inspection storage of medications was satisfactory. All controlled medication and night sedations were fully recorded and the stock balanced. The medications fridge is appropriately used and the temperature is recorded daily. It is recommended that a high/ low thermometer is used and the daily range of temperature is recorded. The Medication Administration Records (MAR’s) were sampled and medication was signed in and checked by two, this included MAR entries that were hand transcribed. Service users were heard to be treated kindly and with respect in all interactions with staff. Staff were seen to knock on bedroom doors before entering and were very polite and helpful. Service users and their visitors confirmed that the home’s staff are kind and helpful at all times. One visitor felt that their relative was ‘treated as a person’, received ‘excellent care’, and staff were so kind’. The care given to frail service users was seen to be considerate and supportive. The service users who were in bed all looked comfortable. All were supported with pillows and some had padded bed rails where there was an assessed need to provide safety from falling out of bed. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 14 Pain control was found to be well managed and the approach to pain control was well thought through and documented to enable staff to make a proactive response to providing pain relief. Evidence of good wound care was seen with the healing of chronic wounds and a proactive holistic approach to the care of any open wounds. One pressure sore only was identified for attention and this was being well managed. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is excellent. Service users are actively encouraged to keep in contact with their family and friends living in the community. Food is considered highly important and meal times considered a social occasion. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not have regular formal activities but there are regular events. These have included a bonfire by popular demand and relatives and friends were invited. The service users are actively involved with the day to day running of the home. Service users are consulted for their views and these influence daily life at Cleeve Court. The home’s staffing has been increased by one person in the afternoon; this was done to ensure there is sufficient staff time for activities and teatime catering. This was in part a response to service users asking for a cooked option at teatime. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 16 A trained Reflexology practitioner has joined the home to offer this specialist therapy. The inspector was also informed that there are plans to increase the activities further to include some exercise therapy. During the afternoon of the second day of the inspection, staff and 6 service users were in the dining room making Christmas cards, the event seemed to be enjoyed by the participants and the cards being made were very good. The home has a regular event where a mascot St Bernard dog visits the home. Many of the service users spoken with said they enjoyed their own company and were pleased to spend their time quietly and as they wished. Most had televisions in their rooms. Many people at the home have lived in the local area and have community contacts. Families visiting their relatives confirmed that they are welcomed and are supported by the homes staff. There is an open door policy at the home and visitors are welcome at any reasonable time. Relatives and friends get involved in the homes activities and events offering their support in return. The inspector heard that past resident’s relatives that remain in touch with the home are invited back to join in with seasonal events, such as the bonfire on November 5th. Lunch was served in the dining room and the meal was nicely presented and looked appetising. The home caters for special dietary needs; diabetic and soft diets were served. The soft and pureed diets were presented in separate portions and looked appetising. Assistance is given as needed, Plate guards and spouted beakers were appropriately used, promoting and assisting the independence of service users with their eating and drinking. Service users told the inspector that the ‘food is very good’, ‘tasty and home made’ and there ‘is plenty and it’s always warm’. Drinks were available with the meal and hot drinks were served during the day. The inspector observed afternoon tea and biscuits being served to service users in their bedrooms, this was nicely done, and the biscuits were all presented on a plate with a serviette. There is a strong emphasis on nutrition and service users dietary needs are assessed and where there is a special need they are monitored. Specialist dietetic advice is sought appropriately. The cook is knowledgeable about the service users dietary needs. The kitchen was well maintained and all cleaning and temperature records were up to date. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is excellent. The home has made the complaints procedure very clear and has provided a safe system for concerns or complaints to be raised directly with the Registered Manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints policy is displayed around the home. Information about CSCI and our role in complaints was available. All service users and relatives said they would be ‘able to complain if they needed to’, some were not sure of the official process. The homes Manager has undertaken to place in each service users room a pack for complaints concerns and compliments. The pack contains the homes complaints process and information about CSCI, a pen, envelopes and a letter inviting service users or their relatives / friends to write to her with their concerns. The delivery is by internal post to the manager. The manager said that the system has been ‘tested by some of her service users’ and she is pleased to have this system and actively promotes all feedback. Staff recruitment was inspected; new starters had Criminal Record Bureau Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 18 (CRB) and PoVA First checks before commencing work at the home. The new induction standards are now in use at the home and these include abuse awareness for staff for the protection of vulnerable adults in their care. Staff that were asked, confirmed that they had received information and training and were aware of their role in the protection of the vulnerable adults in their care. Policies and procedures to protect service users and staff are in place and are accessible to staff. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. The home has a well maintained environment, which provides aids and equipment to meet the care needs of the residents. Where rooms are shared it is only by agreement and screens are provided for privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cleeve Court sits in large grounds and has views from most rooms across the gardens and surrounding countryside. There is both a ramp and a stepped access to the home’s entrance where there is a lot of information on display and the visitor’s book. There is an open door policy and visitors are welcome at any time but must sign in. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 20 A tour of the premises was made. All areas of the home were clean and well maintained. The home was warm and comfortable. The communal lounge and dining room is spacious but very homely and is well used. Bedrooms were sampled, these were comfortable and personalised. Service users spoke of enjoying their rooms and the views onto the gardens and grounds. The beds seen were hospital style and adjustable, but were attractively made up with floral covers and white bed linen. Service users said they found their beds comfortable. A range of equipment was seen in use, bed rails, pressure relieving equipment and special cushions. A sample was cross-referenced and was found to be documented and risk assessed in the care plans. The home is well equipped for assisted bathing facilities and hoists. Staff asked ‘if anything could be improved upon’ mentioned that they had requested an electric hoist for the middle floor rather than the manual style, to make the work a little easier. Mr Bliss later confirmed that he would be purchasing this extra equipment as requested by the staff, for their use. The home has the capacity for four shared rooms, sharing is only with the agreement of the occupant. Only one of the double rooms was in use as shared room at this inspection. Moveable screens are available for privacy in double rooms. One room where a large chair had been removed had no other visitor seating handy for use. The inspector was assured that chairs from the dining room could be taken for extra visitor seating. Infection control was generally good; one catheter bag was seen left in a bedroom, this was later moved for disposal. The inspector also noted that not all hand wash waste bins in communal toilet areas were foot operated flip top type. This is recommended and Mr P Bliss agreed to replace the existing open top bins in these areas. There was good access to aprons and gloves for staff and appropriately placed hand wash / gel and paper towels. Contaminated category ‘E’ waste, sharps and pharmaceutical waste were appropriately managed. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 Quality in this outcome area is excellent. The home has a skill mixed effective workforce who are committed to delivering an excellent quality of care and service to the service users in residence at Cleeve Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a sufficient staff number on duty at this inspection. Staff were seen and spoken with during day one. Two members of staff had worked at the home for a number of years and were very satisfied with their employment. They had undertaken training and development and felt that a good standard of care is delivered at the home. Training and updating was confirmed, this included the mandatory fire training and manual handling training. The home operates a key worker role; this was explored with one member of staff. A relative had praised a key worker highly for their efforts with developing a relationship with the service users and helping them to settle in and be content at Cleeve Court. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 22 Staff are encouraged to undertake training and to keep up to date. The new induction standards have been introduced; examples of the homes induction were seen. The home has been audited and recognised by the University of the West of England (UWE) and will be taking student pre nursing placements for twelve week periods. The home Manager is also a Care Ambassador for North Somerset and attends local schools to promote care working. The manager also works hard to promote good training and standards of care at Cleeve Court. The manager assured the inspector that all students would be fully CRB checked and references taken up prior to coming into the home. There has been a lot of external training that has been put to good use. Extra training that is directly of benefit to the care of the service users at Cleeve Court has included a package for eyesight conditions awareness and wound care input from external agencies. The pre inspection information indicated that 53 of the care staff have an NVQ Level 2 or above, this represents 9 of the 17 care staff. Staff recruitment was sampled and all checks were made and confirmed before a new member of staff or volunteer commenced working at the home. These included the CRB and PoVA First check, verification of identity and two satisfactory references. Registered nurses personal identification numbers (PIN) were verified with the Nursing and Midwifery Council (NMC). Ongoing PIN numbers are checked to ensure that registered nurses remain current on the professional nurses register. Agency staff have been used when holiday cover has been required. The home has produced a pack for agency staff; this pack contains a profile for all service users to fully inform the agency staff of the individuals care needs. An agency nurse was on duty on day two of the inspection. There are no vacancies for care or nursing staff at present. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36,37,38 Quality in this outcome area is excellent. The home is well managed; the management and staff encourage the service users to see the home as their own home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Lin Gill is an experienced registered nurse and registered manager. The home benefits from her enthusiasm and interest in promoting good health and well being in the lifestyle of the service users at Cleeve Court. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 24 There is an open door policy and it was evident from talking with relatives that they feel as supported and as welcome as the service users in residence. Service users spoke confidently about raising any concerns with Mrs Gill and many expressed that they enjoy living at Cleeve Court and one commenting that ‘its like a family’. The manager is well supported by her acting deputy who is also an experienced registered nurse. Staff were seen to be hardworking and all had a very professional approach to their work but with a sense of fun and respect for the service users in their care. The proprietor attended for the duration of day two’s visit and was most helpful with suggestions to improve health and safety issues. This included the purchase of foot operated flip top bins to replace the ones currently in three communal toilets and a proposal to take action with hot surfaces that have regularly required adjustments to keep the surface temperature to a safe limit. Quality Assurance is underway, Mrs Gill has devised questionnaires for her service users that link with the National Minimum Standards to records service users views on the food quality at the home. The menus have been revamped to include feedback and current assessment and dietary advice. Relative’s questionnaires were also sent out in September. Mr P.Bliss also undertakes quarterly surveys for the opinions of service users and relatives, these were sent out in July and October to a sample of four persons each time. Mr Bliss also completes statutory Regulation 26 notifications on a regular monthly basis. These are passed to the inspector at CSCI and are very detailed appraisals of the quality of care on the day. These were validated at this inspection. Diversity is being addressed and training information has been sourced by Mrs Gill to ensure that the right approach is taken towards recognising and managing all aspects of diversity in this care home context. No service user money is managed by the home. All records seen at this inspection were with the exception of the care plans, securely managed. Mr Bliss and Mrs Gill have agreed to the move these records and secure their storage. Staff supervision was demonstrated in the staff files sampled. The maintenance person employed by Mr Bliss is an electrician and attends to all routine maintenance and servicing. Attention was paid to the tumble dryer during the inspection and this was working again on day two. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 25 Records were examined to confirm that all servicing was up to date. Outside contractors attend to the boilers and specialist servicing. Mandatory training for fire was confirmed; this is carried out by an external agent. The home also use a Fire training DVD with a questionnaire, Mrs Gill has adapted this to suit Cleeve Court. Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 26 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 4 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 4 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 3 2 2 Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 27 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. 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. OP38 Refer to Standard Good Practice Recommendations The hot surfaces that require weekly adjustment to retain a safe temperature should be reviewed again and action should be taken to cover these. This will reduce the risk of accidental burning if anyone should fall against one, to a very low level or completely. Records should be stored more securely and in line with Data protection guidance. A minimum / maximum thermometer is recommended for the medications fridge temperature daily monitoring. Foot operated flip top bins are preferable for staff hand wash waste in communal areas. 2 3 4 OP37 OP9 OP26 Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Cleeve Court DS0000020274.V319290.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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