Inspection on 08/12/05 for Cleeve Hill Nursing Home

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/06/07

Cleeve Hill Nursing Home 24/08/06

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 Unannounced Inspection 8th December 2005 10:00 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.V260446.R01.S.doc Version 5.0 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.V260446.R01.S.doc Version 5.0 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 To be appointed 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.V260446.R01.S.doc Version 5.0 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. 28th June 2005 Date of last inspection Brief Description of the Service: Cleeve Hill Nursing Home is situated on the slopes of Cleeve Hill about three miles form Cheltenham. The home as 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. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on one day in December 2005. The acting manager and operations manager were both present during the inspection. The provider was abroad recruiting staff. During the inspection a number of service users and staff were spoken with, to include service users admitted since the last inspection and newly appointed staff. In addition to this a selection of care files and other records were examined in detail and some areas of the home visited, mainly rooms of the service users spoken with. Two of the three requirements and both recommendations made at the last inspection have been met, and one other requirement has been partially met. What the service does well: What has improved since the last inspection? Recruitment procedures have improved a great deal since the last inspection but still require some attention to ensure that they are totally robust. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 6 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 Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 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.V260446.R01.S.doc Version 5.0 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 the following standard(s): 3 The admission process is well managed and with full pre-admission assessments the home ensures that it is able to meet the needs of each service user. EVIDENCE: There have been four new service users admitted since the last inspection and one gentleman was receiving respite care. The records of all the new admissions were examined in detail. Pre admission assessments were completed on all of the newly admitted service users and in one it was recorded that they had visited the home prior to admission. Others had been admitted from hospital or were not well enough to view the home prior to admission but generally a representative had done so on their behalf. Two of the four service users who had been admitted since the last inspection were spoken with and both were satisfied with the standards of care received although one felt that some of the staff did not fully understand her needs. This was fed-back to the acting manager. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 9 One service user also commented that she was not entirely happy with the room she had, but understood it was the only one available when she was admitted and she had been promised another room with a better outlook as soon as one became available. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 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 the following standard(s): 7,9. There is a care planning system in place but this is not very clear and needs to be reviewed in order to provide staff with the information they need to meet service users needs. The medication procedures in this home are well managed promoting good health. EVIDENCE: Six care files were examined in detail, to include all of the service users newly admitted. All had a pre-admission assessment completed but none had an assessment following admission, or a review of the pre-admission assessment. From the assessment, problems are identified and care is planned, with a variety of core and individual care plans. Some of the core care plans have been individualised but not all, and not all the care plans reflect the current needs of the service users. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 11 There were a number of risk assessments completed to include pressure sore, nutritional, falls and moving and handling assessments. In some cases when someone has been identified at high risk, there is no evidence to suggest what action has been taken as a result of this. Unless this is done there is no point to completing the risk assessments. For example several had been assessed as nutritionally at risk, which indicated that the home should seek dietetic advice. This is not done and in most instances records of weight could not be seen. It was later reported that records of weights are put initially into a separate file and then transferred at review. In another example, someone may be identified at high risk of pressure sores but there is no documented evidence of what equipment has been supplied or other action taken. Only two of the records examined had a photograph of the service user. Two of the moving and handling assessments had not been dated and one had neither an admission assessment, or care plans. The gentleman receiving respite care had a social services care plan but not one reviewed or completed by the home. The medication records were checked during the inspection and were well maintained. Since changing to the ‘blister pack system and pre printed medication administration record sheets, there are few hand written entries and all are signed and date correctly. Some of the names have been obscured by the hole punch but the names have been printed clearly elsewhere. Specific note was made of the medication records for the service users whose records were being checked. And all were in order, with the exception of one medication for one service user where an ‘o’ had been recorded against it for 7 days and this was defined as not available. When the manager was asked about this it was reported that the medication had actually been discontinued but this was not indicated on the chart. The dispensing pharmacy carried out their own audit on 14/11/05 and made two requirements for action: to dispose of one unwanted medication and to use the stock available rather than reorder another medication. This is being addressed. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: None of the standards in this section were inspected on this occasion although the home continues to have a wide range of activities available with a varied weekly programme displayed on the notice board. Staff are currently completing a ‘map of life’ for each service user in order to obtain information about their past lives and hobbies and current interests in order to plan meaningful activities. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 16,18 The home has a satisfactory complaints system in place. Policies, procedures and staff training aim to ensure that arrangements for protecting service users from abuse are maintained. EVIDENCE: It was reported that there had been no complaints since the last inspection other than minor concerns about laundry that were dealt with before becoming formal complaints. A copy of the complaints procedure is available in the reception area, as is a ‘thank you’ file. Service users spoken with confirmed that they knew how to complain and who to complain to and were confident that their complaints would be dealt with. From observations around the nurses station it was clear that the staff have a good rapport with the relatives keeping them well informed of residents conditions and supporting them when necessary. Other visitors are also well received. Hospitality is freely available and visitors appear quite comfortable helping themselves to a coffee and sitting in the lounge when a resident was too tired to receive visitors immediately. Another was heard to discuss arrangements with the chef for joining his mother for lunch on Christmas Day. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 14 A Whistle blowing Policy, Prevention of Abuse and the Department of Health Guidance ‘No Secrets’ were all seen and are available to staff. All new staff are expected to read these documents as part of their induction and those undertaking NVQ are also required to refer to these policies as part of their training. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 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 the following standard(s): 19 The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: A full inspection of the building was not undertaken on this occasion but one lounge, the dining rooms and several service users’ rooms were seen and all appeared clean, comfortable and well maintained. All were also comfortably furnished and in good decorative order. No further work has been undertaken on the current heating system in the main, older part of the home but as a major building project is planned to commence in the New Year, major refurbishment will also take place at this time. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 16 The communal areas of the home looked very festive ready for the approaching Christmas celebrations. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staff at the home are well trained and supported and employed in sufficient numbers to meet the residents needs. The procedures for the recruitment of staff have improved providing better safeguards to offer protection to people living in the home. EVIDENCE: On-duty during the inspection for thirty-nine residents were the acting manager and a second registered nurse, with six care staff during the morning and four during the afternoon. Activities staff were also on throughout the day. The operations manager was also available as was the services manager, in a newly created post for the past 2 months. She is responsible for the activities, housekeeping and catering staff. Catering, laundry and cleaning staff were also on-duty. Staff were observed carrying out their duties in a professional manner and it appeared that there were adequate staff on-duty to meet the current needs of the service users. Details are sent to CSCI each month of the dependency of each service user and the calculation of how many staff are required and provided. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 18 The records of two newly appointed staff were checked on this occasion; one a qualified nurse and the other a care assistant. Both had POVA and CRB checks completed. All other required records were found in the staff files with the exception of records of interview and although one had given two names for references and verbal references had been received, written references were not yet available. This must be addressed. Individual staff training records are kept and were seen during the inspection. Five staff gained certificates in Positive Dementia Care following a 3-month course completed in September. Other training this year includes fire training, first aid, health and safety and activity training. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 The acting manager is well supported by her senior staff in providing clear leadership throughout the home with all staff demonstrating awareness of their roles and responsibilities. The systems for resident consultation in the home are good with evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: The acting manager has been in post for over 6 months now and has completed an application form for registered manager, which is to be submitted to CSCI as soon as possible for an interview to be arranged. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 20 From observations and reports from other staff and service users she has accepted the responsibilities of manager well and is waiting to commence an NVQ 4 Registered Managers’ award. The current satisfaction survey is under review and once finalised a new survey will go out to all service users/their families in the New Year, to be completed by them anonymously if they wish. Staff surveys will also go out. In addition to this a programme of audits are underway to include a care plan and care audit to be completed by the operations manager; a medication audit will be completed by the acting manager as will a maintenance audit and staff training audit as part of staff supervision and appraisals; Mrs Flexor will audit administration, catering and housekeeping and the services manager, the activities programme. The financial procedures of the home were not checked in full on this occasion. The home employs someone based in the domiciliary care office to deal with service user fees etc. and holds money securely for service users where necessary. The office in the home does hold small amounts of money for some service users but 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. No health and safety risks were identified on this occasion. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 21 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X X Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 14 Requirement Timescale for action 31/01/06 2 OP8 13(c) 3 OP29 19 4 OP31 8 All service users must have a full assessment completed that identifies individual needs and care plans that reflect current needs, that are reviewed with the residents /their representative whenever possible (timescale of 31/7/05 not met in full). Ensure that any unnecessary risk 31/01/06 to the health of service users are identified and so far as possible eliminated. Two written references to be 31/01/06 obtained for each new employee including a reference related to the person’s last period of employment which involved working with vulnerable adults and a record of interview (timescale of 31/7/05 not met in full). A manager must be appointed 28/02/06 and seek registration with the Commission. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 23 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 2 3 Refer to Standard OP8 OP8 OP9 Good Practice Recommendations Service users should be assessed to identify those service users at risk of developing pressure sores and appropriate intervention is recorded in the care plan. Nutritional screening should be undertaken on admission and periodically, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. Use correct codes/explanations when omitting a medication. Cleeve Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Hill Nursing Home DS0000016410.V260446.R01.S.doc Version 5.0 Page 25 - 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. 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