Inspection on 18/06/07 for Cleeve Hill Nursing Home

This inspection was carried out on 18th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cleeve Hill Nursing Home 24/08/06

Cleeve Hill Nursing Home 08/12/05

Cleeve Hill Nursing Home 28/06/05

Cleeve Hill Nursing Home 24/02/05

Cleeve Hill Nursing Home 25/08/04

Cleeve Hill Nursing Home 26/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Cleeve Hill Nursing Home Cleeve Hill Cheltenham Glos GL52 3PW Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 10:00 18th June 2007 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 Hill Nursing Home DS0000016410.V335282.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 Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Hill Nursing Home Address Cleeve Hill Cheltenham Glos GL52 3PW 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) 01242 672022 Cleeve Hill Healthcare Limited Mary Ann Gangoso Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (2) of places Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate two (2) services users under 65 years of age with physical disabilities on a respite care programme. To accommodate one (1) named service user under 65 years of age. This condition will be removed when the named service user reaches the age of 65 or no longer resides at the home. 24th August 2006 Date of last inspection Brief Description of the Service: Cleeve Hill Nursing Home is situated on the slopes of Cleeve Hill about three miles from Cheltenham. The home has its own grounds of two and a half acres. The premises consist of the original building and purpose built extensions. The accommodation is on two floors accessed by a shaft lift and a stair lift. A ramp from the main corridor to the entrance provides access for wheelchairs. The home provides two communal lounges and dining rooms all overlooking the well maintained gardens with beautiful views of the surrounding countryside. At the front of the home there is an accessible patio area. Major building work has been ongoing over the last year and has improved on catering facilities and has built an extension to accommodate a further eight residents. Now this is completed the home has increased its registration number to fifty, nine specifically with palliative care needs (awaiting new certificate). Building work has now progressed to refurbishment of another wing and will later increase its communal areas and a new reception area will be developed. The garden at the front of the building is also being landscaped and further parking facilities are developed Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are £650 per week for personal care and £750 per week for nursing care. Additional charges are made for hairdressing and toiletries (list of charges provided), chiropody and beautician £10.00, newspapers at cost and telephone according to BT rates. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over fourteen hours on two days in June 2007. During this time the inspector spoke to a number of residents, one relative, staff working in the home and the manager and provider of the home. A tour of the new premises took place and some resident’s rooms and communal areas were seen over the two days. Five resident’s files were examined in detail to include their medication records. Other records examined included quality assurance reports, minutes of meetings and staff recruitment and training records. Surveys were sent to service users prior to the inspection and the results were collated and fed-back at the end of the inspection. A pre inspection questionnaire was sent out several weeks before the inspection and returned to CSCI. Information from this was used when completing the site visit and writing the report. The home also sends monthly audits to the Commission related to dependency levels and accident audits. What the service does well: The people who live at the home are happy with the care provided on the whole, despite some communication difficulties at times and well-trained, enthusiastic and motivated staff maintain a good standard of care. The home has good activities facilities with a wide and varied weekly programme, which through the ‘map of life’ is planned to suit individual needs. Residents and the surveys completed also praised the quality and the choice of food provided. Staff training and supervision is also well organised with staff having access to regular mandatory training updates and a variety of other specialist training such as palliative care. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 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 Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Standard 6 not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have all the information they need to make an informed choice regarding placement at the home, and pre-admission visits take place to ensure that the needs of an individual can be met. Residents normally move in on a long-term basis therefore Std. 6 was not assessed EVIDENCE: The home has revised their Statement of Purpose and Service Users Guide to reflect the changes to the building and use of the home. Just one amendment is required as the guidance refers to NCSC not CSCI with reference to complaints. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 9 Service Users guides were seen in each of the rooms visited and surveys received all confirmed that they were provided with enough information about the home prior to admission. One resident stated that they had moved from a home that had closed but knew it well through visiting relatives and another said relatives had made a couple of visits to the home on their behalf as they were in hospital. Residents spoken with also confirmed the same. Samples of contracts were seen in resident’s files and these have recently been revised in line with Regulation 5a and surveys again confirmed that residents had received a contract. Five residents care files were examined and found to contain a pre-admission assessment form, which gave all the required information to make a decision as to whether needs could be met. Twelve of the thirteen surveys received stated that they always/usually received the care and support they required and residents spoken with confirmed this. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal care and social needs are met through individually planned care and through staff who are trained to meet these needs, whilst respecting their privacy and dignity. People who are terminally ill are also assured that during this phase of their life, staff will treat them with care, sensitivity and respect. EVIDENCE: Five people’s care files were examined in detail and found to have full assessments based on the activities of daily living completed, from which individual care was planned. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 11 All had relevant care plans that reflected their current needs and these were reviewed regularly with the resident or their relatives where possible. Risk assessments such as moving and handling, pressure sore and nutritional risk assessments were also completed and reviewed regularly. Where people had been identified at risk of pressure sores, pressure- relieving equipment such as mattresses and cushions had been provided and where someone was in bed for long periods of time, turning programmes were organised. Records were seen to confirm this and staff also confirmed that this is what they did. Surveys returned stated that they always /usually received the medical support they needed and records and observations confirmed that doctors are called to visit; at least three visited during the two days of inspection and the inspector was able to observe the action taken as a result of their visits. Records and service users spoken with also confirmed visits from other agencies such as the physiotherapist who visits weekly and was also seen and spoken with during the inspection. A treatment room has been built within the new extension and this will be of great benefit to the physiotherapist when it is equipped and ready to use. Others who visit include the speech and language therapist, the stoma nurse, the continence advisor and the Macmillan nurses. All residents may also use the services of visiting chiropodists, dentist and optician. With the opening of the new unit staff have been appointed and trained in palliative care and specific palliative care plans have been compiled. Pain assessment forms are also in use and evidence was seen within daily records of how someone’s pain relief had been adjusted in accordance with their needs. Qualified staff are trained to use syringe drivers to administer analgesia and work closely with doctor’s and the Macmillan nurses. Two residents requiring this service were spoken with and were both very satisfied with the care received. Staff were all observed carrying out their work efficiently and in a professional manner, respecting the service users privacy and dignity. The homes’ aims and objectives within the service users guide include ‘ to treat residents with dignity and to allow privacy whenever required’. The home has a robust medication procedure in place. Records were seen of the service users who were case tracked and were well maintained. Storage arrangements were in place and satisfactory. A random check of the homes’ controlled drugs was completed during the inspection and found to be accurate. Qualified staff carry out a check of all controlled medicines at each shift change. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 12 The dispensing pharmacy carries out 6-monthly audits and the manager also carries out her own medication record audits and sends a copy of the results of these to all the trained staff. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to realise their own preferences and expectations, both in the home and in the community, and are able to maintain contact with friends and family. They also receive a wholesome, appealing and balanced diet in pleasant and comfortable surroundings. EVIDENCE: The home did employ three activities co-ordinators who between them organised an extremely varied and imaginative activities programme which was posted on the notice boards around the home and a copy given to each resident. One has recently left but the home hopes to appoint someone to the post shortly. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 14 At the time of inspection notices for the month had not yet been displayed and some residents spoken with did not realise what was due to take place. Surveys received stated that people were always/usually able to take part in the activities planned but one stated : When I first went to the home lots of things were going on. Now so many of the others are very confused it is impossible to get any activity going .I find it very sad and miss these diversions’. Another said: ‘The activities co-ordinator who was excellent has just retired and she doesn’t seem to have been replaced’. (See above). However, a third said: ‘Activities are very well thought out and arranged and enjoyable’. Speaking to one of the activities organisers and looking at her diary for the month, it appeared that there were a variety of activities planned to include flower arranging, poetry reading and an entertainer, all taking place over the two days of inspection, ball games, quizzes, exercises, trips out and the fete planned for 30th June. A ‘map of life’ is completed for each resident in consultation with them and their relatives and these give a picture of each residents’ past life, work and interests and from this meaningful activities are planned. Not all residents chose to participate but all are offered the choice to join in with which ever activities, social events or outings they choose, or the activities co-ordinators ensure that they receive one to one social interaction. Records are kept of what activities each resident participates in. Visitors are welcomed to the home and may join the residents for a meal. Beverages are available for visitors in the main hall and in the new unit. Only one relative was spoken with on this occasion but several helped to complete surveys and were generally satisfied with the care and facilities provided, as was the one spoken with. Residents all confirmed that they were able to exercise choice and control over their lives, particularly with how they spent their days, the times they got up and retired to bed, and whether they participated in the activities on offer. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 15 Staff were observed maintaining privacy and respect by knocking on doors prior to entering rooms and addressing residents by their preferred form of address. Menus are displayed on the notice board in the corridor by the dining rooms and are also replaced daily on each dining room table. A selection of menus were also provided to the inspector for information. Residents spoken with and surveys received mostly confirmed satisfaction of the meals provided. Comments ranged from: ‘Food is of a very high standard with a good choice at all main meals’, ‘Food is excellent’ and ‘There seems to be a good choice and it is always very well presented’, to ‘After 5 ½ years somewhat repetitive though adequate’, ‘Not particularly. They try hard to titivate food. Plain food with not so many sauces would be preferable’ and ‘There is a good choice of menu. The timing could be better. Supper 5.30 is the final meal’. Special dietary needs are also catered for and discreet assistance offered where necessary. It was also noted that in most instances fluids are readily available to each resident and fluid balance charts in place where necessary. One resident however did ask the inspector for a drink as she had been left in the lounge unable to reach the drinks provided. It was also noted that again there were some communication problems when a member of staff tried to read out the choices of dessert to a resident, who was unable to understand what she said. Another resident eventually made a choice for her. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by the systems in place. EVIDENCE: The home has a complaints procedure included in the service users guide and displayed in the dining room. Resident’s spoken with and most surveys received confirmed that they would know how to complain. The following comments were received when asked if they knew what to do if they were not happy: ‘And they listen’ ‘This does not apply’ ‘ Mum usually asks me to pass on any comments and I now there is always someone I can talk to. Staff are kind and concerned’. ‘ Sometimes (there) maybe a slight breakdown in communication due to staff changeover etc’. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 17 When asked if they knew how to complain: ‘This has not applied’ ‘Mum says she wouldn’t know but she has often voiced her opinions etc. to the staff’. ‘Usually know who to complain to’. One person has complained to the Commission regarding issues related to funding and these have been forwarded on to the provider to deal with. This is currently ongoing as to date the complainant has not been satisfied with the responses given by the provider. The home has policies and procedures on abuse and whistle blowing, updated in January 2007. They refer to the document ‘No Secrets’ but not the Alerter’s Guide. Staff have received training on abuse from a member of staff designated to do this training but it was recommended that she makes contact with the Adult Protection team in Gloucester to ensure that she is up to date with local policies. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Despite major building work ongoing the home remains clean, pleasant and hygienic. EVIDENCE: One stage of the building work is now complete, with improved catering facilities and an extension with nine new spacious en suite rooms offering a facility to care for people who require palliative care. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 19 These facilities were inspected and found to offer bright and comfortable accommodation, built and furnished to very high standards. Most people were very happy with these facilities although two who had moved temporarily were looking forward to returning to their original rooms once refurbished, which is the current work being undertaken. One did not find the en suite bathroom user friendly – ‘no room to put anything’ and another felt the room was dark and preferred their previous room with better views. Other work completed since the last inspection includes the installation of a hydrobath, a new staff room with two toilets and shower facilities, a treatment room for the physiotherapist and hairdresser, two dining rooms refurbished and corridors repainted and re-carpeted. Despite all the building work going on the home was clean and odour free. Residents spoken with and surveys received confirmed this with the following statements: ‘They have managed very well whilst the building work has been going on’. ‘Usually very clean and fresh’. However, some said: ‘Most of the rooms are clean. My room is very ‘tired’. Furniture old and not matching-needs decorating. My showerhead has been leaking for several weeks without being mended’. ‘I think it has been very difficult for all the staff while the building work is being done. However, I pay a lot of money each week and feel that some of it should be used to improve existing rooms’. ‘Equipment, e.g. radiator not always functioning- may be owing to, as yet unfinished development’. All of the above comments were fed- back to the provider and manager. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. People living at the home have their physical needs met by staff skilled to meet those needs but this is hampered in some areas by poor communication skills of some of the staff despite being supported to undertake regular and relevant training. People living in the home are fully not protected by the homes recruitment system. EVIDENCE: Adequate numbers of staff were on-duty during the inspection to meet the needs of the residents and copies of rotas were seen/provided for the inspection. A monthly staff requirement calculator is also sent to the Commission, which calculates the numbers of staff required against the current dependency levels. What must also be taken into account is the layout of the building, which is very large, however, a new call system has proved very beneficial in calling for assistance and locating staff around the building. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 21 A number of staff were spoken with to include several new staff recruited from overseas. Some were able to give accurate information about the service users they were responsible for and how to meet their needs. However, there are still some communication problems with some of the overseas staff, who were unable to give a clear indication of what care they had given that morning and to whom, and were unable to communicate what they would do if a resident complained of being in pain. Service Users spoken with confirmed the good standards of care, although some said communication was not always easy. In response to the question ‘do staff always listen and act on what you say’? One survey said: ‘Some do, some don’t. It is difficult with so many foreign staff to make them understand’. Another said: ‘I think the problem is that I cannot always understand what the carers are saying and they don’t always understand me. They try very hard but some have very little English’. The provider has organised English classes for all the overseas staff and they were undertaking a test during the afternoon of the inspection but unfortunately when they arrive at the home their level of speech and understanding is not always acceptable. Nine staff files were examined on this occasion, of all the new staff identified from the pre inspection questionnaire, started since the last inspection. The home does employ a large number of its staff from overseas and of the nine files checked six were from overseas in care, domestic and maintenance positions. All had completed an application form, all but one had photographic identification and in most cases had also completed a curriculum vitae but not all had full carer details, reasons given for leaving positions, or specific details about positions held. As there were only two with interview records, it could not be verified that gaps in employment or any queries had been followed up satisfactorily. The provider stated that interviews of overseas staff (undertaken by a third party overseas) were being improved upon. Only one of the nine seen had POVA first completed before commencing work. The length of time worked ranged between 2 days for one British employee to 41- 44 days, for two overseas employees. Two had no references and two others unsatisfactory references for example one handwritten from a husband of the employee and one where the last Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 22 employer of a care home was not willing to give a reference but gave information about the employee over the phone and there were discrepancies in the dates worked in this instance. All of this information was fed-back to the provider and an immediate requirement notice was given to not employ any more staff until POVA First had been obtained and then for these staff to work under supervision until CRB disclosure received. This is an outstanding requirement from the last inspection and failure to comply will result in further action being taken. The pre inspection questionnaire indicates that 8 staff already have NVQ level 2 or above and 4 more are currently undertaking this. It also recorded recent staff training to include moving and handling, first aid, fire training, health and safety, food hygiene, infection control and abuse training. Some certification seen in staff records, the training matrix (not up to date) and staff themselves, confirmed this. Qualified nursing staff have also received training in ear syringing, venepuncture, catheterisation, syringe driver, End of life training, drug update, continence care and wound care. All of the above training is on-going and will be repeated where necessary. Concerns were again raised about the levels of understanding of the training that overseas staff have received but the inspector was assured that following most of the training given, especially health and safety training a questionnaire is completed to check levels of understanding. Moving and handling training includes practical sessions but as poor moving and handling was observed (see standard 38) there is a possibility that staff do not understand the dangers of poor practices. One member of staff from overseas was asked about use of aprons and gloves, and clearly was unsure stating that gloves were changed between each resident but aprons were not always. It was also observed that all staff appear to wear gloves all the time when giving care which may not be totally necessary. Cleeve Hill Nursing Home DS0000016410.V335282.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, 33,35, 36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by the manager who is committed to her responsibilities, even though not totally involved in all aspects of management. Her approach is open and inclusive. The home is run in the best interests of those living here. Systems are generally in place to protect both residents and staff but some aspects such as moving and handling procedures need to be improved upon to safeguard residents and staff. Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has now completed the registered manager’s award. She appears to be managing the home quite well especially in this time of transition but is not always involved in recruitment of staff, especially when this is carried out overseas. Regular staff meetings are held at all levels and minutes of these meetings were seen. The last residents meeting was in June 2007 and the next planned for 16th August; the last staff and registered nurse meetings were held in May and the general staff and night staff meetings in June. One resident spoken with felt that neither the manager or provider visited the residents on a one to one basis as much as they used to and felt that not all residents felt confident to talk at a meeting. However, others spoken with said they saw both regularly and were confident of their support if they had any concerns. The manager completes annual appraisals for all staff currently and supervisions of carers is completed by senior care staff, who are also responsible for the induction of new staff. This is an ongoing process and each periods of instruction is classed as a supervision session but is not yet being recorded as such, consequently the home does not appear to be meeting the recommended 6 supervision sessions each year for care staff, which must be addressed. The home holds small amounts of ‘pocket money’ securely for service users where necessary and requested. Individual records and receipts are kept of any financial transactions undertaken, and were seen. Monies for hairdressing, chiropody etc. is generally billed individually and sent out in a monthly invoice to each service user/their representative. Residents are able to purchase confectionery, toiletries and certain items of clothing from the home and price lists are included both in their information and were provided with the pre-inspection questionnaire. Again records are kept of all these transactions. The last satisfaction survey was sent out to service users/their families in February 2007. 66 of surveys were returned. These looked at all aspects of the home and on the whole were quite positive. Although it was reported action has been completed where necessary, this has not been included on the Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 25 results form provided to the Commission. A copy should also be included in the service users guide. The provider ensures that the service users and staff are kept safe particularly during the building works. Staff spoken with and records seen confirmed that all staff receive mandatory training on induction and regular updates. However, there were two instances noted where moving and handling assessments stated that someone should only be moved by two staff using a hoist and staff were observed transferring them from chair to wheelchair without the use of a hoist. This was fed-back to both with the manager and the moving and handling trainer. Records seen confirmed that regular servicing and maintenance of equipment is carried out, but some comments from residents and their relatives seen earlier in the report suggest that some routine maintenance is being overshadowed by the current building project. Cleeve Hill Nursing Home DS0000016410.V335282.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP29 Regulation 19(4)(c) Requirement Two written references to be obtained for each new employee. The registered person should also ensure that they are satisfied on reasonable grounds as to the authenticity of the references. Timescale of 31/10/06 not met. This requirement has been repeated from the last two inspections. The registered person must obtain the following pre employment checks: A full employment history, together with a satisfactory written explanation of any gaps in employment. Criminal Records Disclosure (including where applicable a POVA check). New employees must not commence work until POVA First has been completed. Timescale of 31/10/06 not met. This requirement has been repeated from the last inspection. An immediate requirement notice has been given. DS0000016410.V335282.R01.S.doc Timescale for action 31/07/07 2. OP29 19(2) 31/07/07 Cleeve Hill Nursing Home Version 5.2 Page 28 3. OP33 24 The report in respect of any quality assurance reviews undertaken must include details of the measures taken in order to improve the quality and delivery of the services provided in the home. Timescale of 28/02/07 not met in full. This requirement has been repeated from the last inspection. A safe system for moving and handling service users must be put in place to ensure that people receiving care are not put at risk by poor moving and handling procedures, 31/12/07 4. OP38 13(5) 31/07/07 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 OP29 Good Practice Recommendations An interview record should be kept to explore any discrepancies/gaps in career history and reasons for leaving previous positions. The results of service user surveys are published and made available to current and prospective service users, their representatives and other interested parties including CSCI. Care staff should receive formal supervision at least 6 times a year. 2. OP33 2 OP36 Cleeve Hill Nursing Home DS0000016410.V335282.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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