Inspection on 10/03/09 for Cleeve House

This inspection was carried out on 10th March 2009.

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 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 House 30/03/10

Cleeve House 28/01/10

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Cleeve House 49 Hornyold Road Malvern Worcestershire WR14 1QH Lead Inspector Sarah Blake Key Unannounced Inspection 10th March 2009 09:30 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 House DS0000071461.V374542.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 House DS0000071461.V374542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve House Address 49 Hornyold Road Malvern Worcestershire WR14 1QH 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) 01684 564 454 01684 573 637 Cleeve House Care Ltd Mrs Breda Anne Goulding Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 16 The maximum number of service users to be accommodated is 16. 2. Date of last inspection Brief Description of the Service: Cleeve House is registered to provide residential care for up to sixteen older people who are frail, with mild to moderate personal care needs. The large, detached, Victorian property is situated in a pleasant residential area of Malvern, approximately one mile from the town centre. There is an established and well-maintained garden which is accessible to people living at the home. The original house has been extended on the ground floor. The home is owned by Cleeve House Care Ltd. The responsible person is Mr Darren Mills, and the registered manager, with responsibility for the day to day running of the home, is Ms Breda Goulding. Information about the fees is available on request from the home. A copy of this inspection report can be viewed at the home. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. We spent a day at the home, talking to the people who use the service and the staff, and looking at the records, which must be kept by the home to show that it is being run properly. These include records relating to the care of people who use the service. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. Some of the manager’s comments have been included within this inspection report. We also received completed survey forms from people who use the service, their relatives and health professionals who work with the home. The information from these sources helps us understand how well the home is meeting the needs of the people using the service. What the service does well: The home provides good information to help people decide if they wish to move into Cleeve House. People can be confident that their needs will be assessed before they move in, so that they can be sure that the home is suitable for them. The home provides a varied menu of home-cooked food, which provides a nutritious and balanced diet. People who use the service know how to raise any issues which concern them. The home’s procedures for managing complaints mean that people who use the service can be sure that any complaints will be managed satisfactorily. Cleeve House provides a safe and comfortable environment, with a friendly and welcoming atmosphere. The home is kept clean, and infection control is well managed. There are sufficient staff on duty to meet the needs of people living at the home. Staff recruitment protects the people living at the home by ensuring that only suitable people are employed. Staff receive regular training. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 6 The home is managed in the best interests of the people who live there. The health and wellbeing of the people who live at the home is given a high priority. 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 House DS0000071461.V374542.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 House DS0000071461.V374542.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): Quality in this outcome area is good. The home provides good information to help people decide if they wish to move into Cleeve House. People can be confident that their needs will be assessed before they move in, so that they can be sure that the home is suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that the home has a detailed Service User Guide and Statement of Purpose, and the manager told us in the AQAA that a copy of this is given to anyone who might be thinking of moving into Cleeve House. The Service User Guide includes information which clearly explains what it is like to live at the home. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 9 In our surveys, people told us that they had been given enough information to help them decide whether or not they wished to move into the home. The manager told us in the AQAA The individual and their family/advocate is invited and encouraged to visit the home and spend some time there. One person told us my daughter said she had lots of information so I was happy moving in. We saw that the home has a pre-admission assessment form, which is completed before people move into the home. By completing this assessment, the home can be sure that it can meet the needs of everyone who moves in, and staff have the information they need to know so that they can provide care for people as soon as they move in. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is adequate. People who use the service cannot always be confident that all their care needs will be met. The home does not manage medication in a way which protects the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Everyone living at the home has a written plan which gives information about peoples needs, wishes and preferences. We looked in detail at three peoples written plans. At the front of the care plans there is an index, which clearly explains the purpose of each part of the care plan. For example, the section on Personal Care includes the information This will tell you what support I need with my personal care for washing and bathing. It will tell you how much I am able to do for myself and how you can encourage me to be more independent. We Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 11 saw that people had signed their agreement to the care plans. This shows that the home is making sure that people can be involved in planning their own care, and that they have the information they need to enable them to take part in the planning. We saw that the care plans were person-centred, which means that they focus on each persons individual needs and wishes. Each aspect of the persons life had been considered and we saw that the plans generally gave good information so that staff would know how to support each individual person. One persons plan stated A (name of person) can get upset and stressed when in a group setting. For this reason, A sits with one other lady, rather than in a large group. We saw that, at lunchtime, A was sitting at a table with one other person. This shows that staff are aware of peoples preferences and put this awareness into practice. Care plans included information about the importance of respecting peoples wishes. One persons care plan stated ask B (name of person) if it is OK for you to put her hearing aid in. We saw that the file for a person with diabetes included clear information for staff to tell them what to do in an emergency, and also details of the specialist needs associated with diabetes, such as foot care. We saw that the home had not recently recorded the weight of some people who may be at risk of malnutrition. One persons records stated has lost weight over the last year steadily. Her GP has been informed. We saw that this person had lost over one stone in weight from January to November 2008, but that there had been no weight recorded since then. There was no plan in her file to show how the home was managing her nutritional needs. One persons nutritional assessment indicated no risk, but elsewhere in the care plan the manager had written Social Worker was concerned that she looked like she had lost weight. The records showed that she had not been weighed since moving into the home. The manager told us that this was because some peoples mobility needs mean that they cannot be weighed by standing on scales. We would expect the home to provide facilities for everyone who is at risk of weight loss to be weighed regularly. The manager told us that she is in the process of making sure that everyones care plans and risk assessments are up to date and complete, but that she recognises that not all the documentation is yet to the required standard. Although it is important that records are kept to a high standard, it is more important to ensure that peoples needs are being met. The daily records showed that the home contacts health professionals, such as GPs and District Nurses, when necessary. Surveys completed by health professionals told us that the home always or usually seeks advice from them and acts upon it. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 12 On the day of the inspection, we saw staff providing care for people in a way which promoted their privacy and dignity. The staff always knocked before entering bedrooms, and explained any procedures clearly to people. All medication charts were looked at including the storage and handling of medication. A general medication policy was available, however it was not dated or signed and there was no evidence that staff had read and agreed to follow the working medication policy to ensure that people living at the home were safeguarded. The majority of medication we saw was stored in locked cupboards and also within a locked medicine trolley. A new metal locked cabinet was available. We saw medication stored neatly and tidily, which ensured that peoples medication could be easily located. However, we saw some eye preparations were stored next to creams for external use, which increases the risk of contamination and may be harmful to people who use the service. Medication requiring refrigeration was stored in a refrigerator and the temperatures recorded by staff were within the correct temperature range for safe medication storage. A staff signature list was seen, however staff had not signed their initials as documented on the medication administrations record (MAR) charts. This means that the records were not clear and it was difficult to know which member of staff had administered medication. Sometimes an unknown code was used on the MAR charts that were confusing. For example, we saw a letter ‘J’ used on several occasions which was not a staff signature or a recognised code to explain why medication had not been administered. We asked the Deputy Manager to explain what ‘J’ meant and he explained that it was used when a resident was asleep. This was confusing because there was a code ‘F’ that could be used for ‘other’ reason why medication was not administered and staff would need to document the reason on the reverse of the MAR. This had not been done. The MAR records were therefore confusing and did not ensure that the medication administration was clearly documented. We looked at the current medicine administration records and although staff were signing the record for administration it was not always consistent. Some charts had gaps with no signature or a reason documented for not administering the medication. It was particularly seen for people who were prescribed eye preparations or external preparations such as creams or ointments. For example, one person was prescribed an eye preparation twice a day to treat glaucoma, however there was no record of administration for two consecutive days at lunchtime. We were shown a book by the Deputy Manager that was used to document all the gaps on the MAR charts and to identify which member of staff had been on duty. It was not clear what action was Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 13 being taken to prevent this occurring on a regular basis. This means that some of the records were not accurate and were incomplete. This increases the risk of medication error and of people not receiving their medication as prescribed. We asked the Manager if staff who administered medication had been assessed as competent. The manager informed us that the competency checks had been done which included checking that staff were signing the medication records for the administration of medication. The written evidence of these checks was available during the inspection. Records for the receipt of medication were not always clear and accurate. For example, the receipt of one persons medication was not documented, which made it difficult to check the records and ensure that medication was being administered safely. There were disposal records available, which helped to ensure accurate documentation of medication being returned to the pharmacy was kept. We found that a number of people who were using the service were holding and administering part of their own medication. We found documented assessment of the risks, associated with this activity. They appeared to be detailed and included specific information about the risks. It was therefore disappointing that when we spoke to two people who use the service, the risks had not been fully recorded and identified. For example, one person kept medication in an unlocked cupboard, which had not been identified in the risk assessment. The second person we spoke to confirmed that there was no medication stored in the bedroom and never had been, however the risk assessment form stated ‘C (name of person) wants to be independent. She wants to hold her creams in her room’. This means that due to incomplete risk assessments there is an increased risk to the health and general welfare of the people who use the service. We looked at the care plans for one person who was highly physically dependent together with the medication administration records. We saw detailed information dated December 2008 about the persons current medication requirements. The medication records seen indicated that the person was often asleep during the morning medication administration at 0800 hours, however the records were not always clear. For example various codes were recorded for asleep or refused and some had been crossed out and then signed by a member of staff. The care plan for the ‘Waking routine’ was seen and stated ‘D (name of person) usually rises around 9-9.30am’, there was nothing recorded about any issues relating to medication administration. The Deputy Manager informed us that the Doctor had been informed that the person often refused the medication, however there was no recent documentation available relating to communication with a doctor. The last recorded doctor’s visit was made on 27 January 2009 which stated ‘…Doctor is happy with D not taking her tablets as long as they are not refused every day of the week…’, however there was no further communication documented regarding the continued refusal of medication. This means that due to poor Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 14 records and documentation the health and medication requirements of the person were at risk. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is adequate. People living at the home have access to a limited range of social and leisure activities. Food is of a good standard, and provides a nutritious and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Surveys from seven people living at the home indicated that they felt that there were not always sufficient activities organised by the home. Comments included we used to do activities every afternoon but now we dont do much and I get bored and only someone who came in to sing - no other activities. The manager told us in the AQAA we have times set aside for activities (individuals and groups) together with activities targeted for our less mobile, more vulnerable residents. The activities are the responsibility of a designated member of staff each day and records are kept on a day to day basis. We looked at the records of activities, and saw that the only activities recorded since the beginning of the year were one visit from a singer; two people Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 16 attending church on one occasion; one reminiscence activity; and three nail care sessions. We spoke with people living at the home and one person told us theres nothing much to do, I just sit here, whilst another said Im quite happy in my own company. The manager told us that she has tried to arrange activities, such as an outing to see the Christmas lights, but nobody has been interested in taking part. We would expect to see records to show that a range of activities has been provided, so that people can join in on the day if they wish to. The manager told us that a mobile shop visits monthly, and this is very popular with people living at the home. We saw from the records that people are supported to attend a place of worship if they wish to. People told us that their families and friends can visit at any time. We saw that families were made welcome, and obviously felt comfortable in the home. One persons relative told us everyone here is very friendly, they never make you feel as if things are too much trouble. We saw that the home provides a menu which is rotated on a four weekly basis. The menu shows that the home provides a nutritious and balanced diet. Food is home cooked, and people told us that they appreciate the fresh vegetables. On the day of the inspection, lunch was cottage pie with cauliflower and carrots, followed by jam sponge and custard. The food looked appetising and was well presented. People told us lunch is usually lovely, the foods always hot, theres always fruit if you want it and theres a nice variety of food and puddings. People also told us that, if they dont like the food that is on the menu, the staff will always cook something different for them. We saw that the home has taken advice from specialist nurses to help them provide a balanced diet for people with diabetes. We saw that people with diabetes had been offered a different pudding at lunchtime. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is good. People who use the service know how to raise any issues which concern them. The home’s procedures for managing complaints mean that people who use the service can be sure that any complaints will be managed satisfactorily. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us in the AQAA There is a simple, clear and accessible complaints procedure. All complaints are dealt with in a prompt and effective manner. We saw that the complaints procedure was displayed in the reception area of the home. In our surveys, people living at the home told us that they knew who to speak to if they had any concerns. The people we spoke with on the day of the inspection all said that they knew how to complain if they needed to. One person said Ive never needed to complain, but Id talk to F (one of the senior staff), shes very kind. The home has not received any complaints. We, the commission, were informed of an anonymous allegation against the home, which was investigated by the Local Authority under its procedures for safeguarding Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 18 vulnerable people. The Local Authority was satisfied that the home was not placing anyone living there at risk. Staff at the home receive training in how to protect people from abuse, and they know who to speak to if they have any concerns about possible abuse or neglect. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is good. Cleeve House provides a safe and comfortable environment, with a friendly and welcoming atmosphere. The home is kept clean, and infection control is well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cleeve House is a detached house, which has been adapted to meet the needs of the people who live there, without losing its character. Some of the décor is a little shabby and would benefit from some updating, but the manager told us that there is a programme of refurbishment, and we saw that the downstairs hall and reception area have recently been repainted. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 20 The home was seen to be generally clean and tidy. The home has two lounges, and the manager told us that they are both due for some redecoration. The dining room is a very pleasant and airy room, with tables spaced so that everyone has plenty of room to eat in comfort. The home has a stair lift for people with mobility problems, but there is no other lift access to the upper floor, so anyone who uses a wheelchair would have to be accommodated on the ground floor. We saw that people had personalised their bedrooms with ornaments and articles of furniture. The bedrooms were clean and comfortable, and people told us the cleaners are in every day and its always nice and clean. The garden is large, and has a well-kept patio area with a covered gazebo and wooden garden furniture. There is a small lawn area and the manager has plans to involve people living at the home in planting vegetables and patio plants next year. Staff at the home have a good understanding of the principles of infection control. We saw staff wearing aprons and gloves to provide personal care to people, and there was alcohol gel available in the reception area for visitors to use. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is good. There are sufficient staff on duty to meet the needs of people living at the home. Staff recruitment protects the people living at the home by ensuring that only suitable people are employed. Staff receive regular training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who completed our surveys told us that the staff at Cleeve House are kind and caring. Comments included the staff listen and help me with what I need and if I ask for things, the staff will always do it for me. On the day of the inspection we saw that staff were kind and respectful when supporting people with any tasks. One member of staff was seen to explain clearly and patiently to someone how she was going to assist them to move. We saw that one person who cannot walk without assistance had her call bell placed close by her in her bedroom, and she confirmed that staff were always careful to make sure it was within reach. People told us that the staff respond quickly when called. One person said yes, they always come if I call and Ive never had to wait and another told us they come if I need them. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 22 Staffing rotas showed that there are enough staff on duty to meet the needs of the people living at the home. The manager had responded to a concern that there were not always enough staff in the afternoons by allocating an extra member of staff. The home has robust recruitment procedures which help to make sure that only suitable staff are employed. We looked at records for two members of staff. These showed that all the necessary checks had been carried out before the staff began work at Cleeve House. These checks include a Criminal Records Bureau (CRB) check and two written references, one of which is from a previous employer. We saw training records which showed that staff receive all the required training to give them the skills and knowledge they need to work at the home. This includes training in moving and handling, fire safety, first aid and health and safety. Some specialist training has been provided, such as palliative care training at the local hospice. Staff told us that they felt well supported by the manager. One member of staff told us I am able to talk to or approach my manager when needed. Cleeve House DS0000071461.V374542.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): Quality in this outcome area is good. The home is managed in the best interests of the people who live there. The health and wellbeing of the people who live at the home is given a high priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, Breda Goulding, is registered with the commission. This means that she has been judged to be of good character and to have the skills and knowledge to manage the home. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 24 The home is in the process of carrying out quality assurance surveys, using the expertise of a specialist consultant, and we saw that this would involve everyone living at the home, families and other people with an interest in the home, such as health and social care professionals. The manager told us that the results of these surveys would be used to make improvements to the service. The home does not take responsibility for peoples personal money. We saw records which showed that the owner visits the home regularly, and provides written reports of his visits, which include action points for the manager. The manager completed the AQAA and sent it to us when we asked for it. It included detailed information about the home, and told us that the manager knows how the service can make improvements. The manager shows a clear commitment to ensuring the health and safety of everyone living at the home. Records showed that, when something has been brought to her attention, she has made the necessary improvements. She has a good knowledge of the needs of each person living at the home, and it was clear to see that people who live at the home, their families and the staff all find her approachable. We received positive comments about the management of the home from health and social care professionals. One social worker told us the manager is trying hard to make positive improvements and appears to be succeeding, and a GP said the staff can be proud of the high standard they achieve. Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP8 Regulation 12 (1)(b) Requirement You must ensure that people who are at risk of not having their nutritional needs met, and are therefore at risk of weight loss, have access to facilities to enable accurate monitoring of weight. This is to ensure that peoples nutritional needs are met. You must ensure that the outcome of risk assessments is used to inform care planning. This is to ensure that people are not at risk of harm or injury. Records for the administration of medication must ensure that the record states what medication was administered, when it was administered, who administered the medication or a specific reason is documented if it is not administered. This is to ensure that the administration is documented and that medication is administered according to the directions of a medical professional in order to ensure that the people who use the DS0000071461.V374542.R01.S.doc Timescale for action 30/04/09 2. OP8 13 (4) (c) 30/04/09 3. OP9 13 (2) 30/04/09 Cleeve House Version 5.2 Page 27 service are safeguarded. 4. OP9 13 (2) The date of receipt of medication 30/04/09 must be available in order that accurate records of medication are retained in the home to ensure that the health and welfare of people are safeguarded. A system should be introduced to ensure that accurate medicine audits can be done and check that people who use the service have been administered medication according to the directions of a Medical Practitioner. Risk assessments for the selfadministration of medication must ensure that all risks are identified to protect the resident and other people within the home from any harm. Storage of medication that is for use in the eyes or to be taken orally by mouth must be stored separately from any medication intended for external use. This is to ensure there is no risk of contamination of peoples medication. Healthcare records for medication including any changes made by a healthcare professional must be complete, up to date and easy to locate within the residents care plan. This is to ensure the safety of residents. 30/04/09 5. OP9 13 (2) 6. OP9 13 (2) 30/04/09 7. OP9 13 (2) 30/04/09 8. OP9 13 (2) 30/04/09 Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations The medicine policy should be dated and reviewed in order to ensure it is specific to the service and that the health and welfare of service users taking medication are safeguarded. A list of staff initials who administer medication should be available in order to identify who has administered medication to the residents. You should ensure that people who use the service have access to social and leisure activities which meet their needs. 2. OP9 3. OP12 Cleeve House DS0000071461.V374542.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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