Inspection on 28/01/10 for Cleeve House

This inspection was carried out on 28th January 2010.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cleeve House 30/03/10

Cleeve House 10/03/09

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 18/06/2010.

Key inspection report Care homes for older people Name: Address: Cleeve House 49 Hornyold Road Malvern Worcestershire WR14 1QH     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sarah Blake     Date: 0 3 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Cleeve House 49 Hornyold Road Malvern Worcestershire WR14 1QH 01684564454 01684573637 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Cleeve House Care Ltd Name of registered manager (if applicable) Mrs Breda Anne Goulding Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 16. 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 Date of last inspection Brief description of the care home 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 Care Homes for Older People Page 4 of 37 Over 65 16 0 Brief description of the care home 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. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection. Two inspectors, including a pharmacist inspector, visited 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. We looked in detail at the records for three people living at the home. 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 managers 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 Care Homes for Older People Page 6 of 37 sources helps us understand how well the home is meeting the needs of the people using the service. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Older People Page 8 of 37 order line 0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides information for people to help them decide if they wish to move into Cleeve House. Peoples individual needs are assessed before they move in, so that staff know the care that needs to be provided. Evidence: People told us that the home had provided them with written information before they moved in. This had helped them to make an informed choice about whether Cleeve House was the right place for them. We saw that the Statement of Purpose included useful information about the home. The Service User Guide had not been updated since the change of ownership in 2009, so some of it was out of date and did not give correct information about, for example, who the registered provider is and how to contact him. Since the inspection, the manager has sent us an updated Service User Guide. Care Homes for Older People Page 11 of 37 Evidence: We looked at the records for one person who had recently moved into the home. The person had moved in as an emergency, so the manager had not been able to carry out a pre-admission assessment. We saw that an assessment of the persons needs had been carried out as soon as the person had arrived at the home. The assessment clearly identified the persons needs, and gave staff the information they needed so that they could provide the care that was required. In the AQAA, the manager told us that she carries out assessments of peoples needs before they move in, wherever possible. The manager told us that people are encouraged to visit the home before they decide if it the right place for them, and, in the AQAA, she told us All persons move in on a trial basis, which is reviewed between 3-4 weeks before they and/or their representatives make a decision to stay. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be confident that their health and personal care needs will be fully met at the home. The management of medication continues to place people at risk of harm. Evidence: We looked at the care plans for three people who live at the home. We saw that care plans had been regularly reviewed and updated, and were written in a person-centred way, with an emphasis on protecting peoples privacy and dignity. The Alzheimers Society explains how person-centred care works: Instead of treating the person as a collection of symptoms and behaviours to be controlled, person-centred care considers the whole person, taking into account each individuals unique qualities, abilities, interests, preferences and needs. The manager told us in the AQAA residents are assessed and cared for as individuals. We talked to staff, who showed a good understanding of each persons needs. Care plans included detailed information about each persons wishes, and records showed that people are encouraged to exercise choice in all aspects of their lives. Care Homes for Older People Page 13 of 37 Evidence: We saw that one person needed assistance from staff to help them to mobilise. The care plan explained in detail how staff should help them, and gave clear instructions for the use of specialist equipment. One relative told us about a time when their family member had been very ill: I couldnt believe how attentive the staff were; they kept her really clean and generally did a great job. The daily records were seen to be detailed and informative. We saw that one persons daily record stated that on one day: no bath given due to short staff, B (name of person) not happy this evening due to not being given a bath. The rota showed that only the manager and one carer were on duty at the time. This means that the persons needs were not met because of a lack of staff. We have written to the registered provider, requiring him to ensure that the numbers of staff are appropriate to the assessed needs of people living at the home, taking into account their individual health and personal care needs, at all times. We say more about this in the Staffing section of the report. We saw that staff had recorded in the daily records for another person red sore on right cheek of bottom sudocrem applied please monitor. This person had been assessed as being at very high risk of developing pressure sores. There was no record of any monitoring, and there was no care plan to inform staff what to do to prevent pressure sores for this person, such as regular repositioning, although there was a leaflet in the care plan file with some general information. There was no record that the District Nurses had been asked for their advice. We told the manager to contact the District Nurses, and she subsequently informed us that this had been done. We observed that the person was being turned regularly, but it is very important that staff have access to an individual plan for the prevention of pressure sores, so that there is continuity of care. The pharmacist inspector visited the home on 28th January 2010 to check the management and control of medicines. We arrived at 11:00am and stayed until 17:00pm. We looked at medicine storage, medicine records and three peoples care plans. We spoke to three members of staff and the manager. We found that the majority of medication was locked and secured in two medicine trolleys or locked cupboards to ensure safe keeping. However, the medicine cupboard used to store peoples prescribed creams and ointments was not locked. A note attached to the door, stated Do not leave these doors open!, which appeared to suggest that the cupboard was not always secure. When we returned to the home on Care Homes for Older People Page 14 of 37 Evidence: 3rd February 2010, we saw that this cupboard was again unlocked, and the downstairs medicine trolley was not secured to the wall. An envelope containing money for a person living in the home was seen inside one of the medicine cupboards and not in the safe. We discussed with the manager safe storage of peoples medication and safe keeping and recording of peoples personal money. We say more about the management of peoples personal money in the Management and Administration section of the report. We looked at all the current MAR charts from 4th January 2010 and saw that there was no record of receipt documented for the majority of medicines, no records of any balances of medication carried forward from a previous MAR chart and the date of opening on some medicines were not recorded. This means it was difficult to check if medication had been given as prescribed. We spoke to the Manager who was surprised there were no records available and said that all staff are aware of correct procedure. We were shown previous MAR charts which did record the date of receipt of medication and the amount of medicine carried forward from a previous MAR chart. We were shown a book that the Manager used to record weekly medication stock checks. The last stock check was dated 20th January 2010. We looked at the MAR charts for one person prescribed nine different tablets and checked the medicine available in the home. We found that five of the checks were accurate but there were discrepancies for four of the medicines which could not be accounted for. This means that due to poor records it was not always clear if people had been given their medicines as prescribed. This had been identified at the previous inspections. We found that care staff had not given a person their prescribed medicine for the prevention of osteoporosis. The tablet was to be given once a week before breakfast. We saw that a code o had been documented on the MAR chart for three dates, which means that the tablet had not been given for three weeks. The code o had not been defined on the MAR chart, however there was a record on the back of the MAR chart which stated that the tablet had not been given as the person had already eaten breakfast. We discussed this with the manager who could not give an explanation. There was no evidence that further advice had been taken to ensure the person was given their medicine. This means that the person had not been given their prescribed medication, staff had not ensured that the person was given the tablet before eating breakfast and had not checked with a healthcare professional for further advice. There were three duplicate MAR charts in use for the person, which was confusing. Each MAR chart was started on a different date. For example, the tablet prescribed for osteoporosis was documented onto each MAR chart. It took a considerable amount of time to check the records because different dates were signed in duplicate and some Care Homes for Older People Page 15 of 37 Evidence: had been left blank but had been signed as given on another MAR chart. We showed the three MAR charts to the Manager who explained that the home was having some problems with the pharmacy but could not explain why there were three MAR charts all with interlinking dates. This means that due to poor medicine records there was an increased risk of a medication error. Risk assessments for the storage of medication in peoples bedrooms were not available. For example, we found that one person was looking after their own insulin in their bedroom. We spoke to a member of staff who informed us that the person looked after their own insulin and staff assisted in the administration. We were shown a risk assessment dated 22nd May 2005 and reviewed in December 2009 which explained that the person was able to administer the insulin; however there was no risk assessment for the safe storage of insulin in the persons bedroom. This means that there was no record of a risk assessment to ensure the safety of the person or for other people who live in the service. The manager described to us the process for supporting the person to administer the insulin, and this included staff resheathing the needle after the person had injected the insulin. It is not good practice to resheath needles as this increases the risk of a needlestick injury. The manager told us that the home does not have a policy and procedure for the management of needlestick injuries, even though staff are involved in handling insulin pens and also using lancets for monitoring blood glucose levels. When we looked in one persons care plan we found that they were being given a medicine hidden in a drink, which is also known as covert administration of medication. This was not documented on the persons MAR chart and there were no written instructions for staff to follow. We saw a record which stated that the doctor said to speak to a pharmacist about covert methods and what to put medication in. We saw no record of communication with a pharmacist. We looked in the persons care plan. There was no assessment recorded to explain the reasons why covert administration was required or information about how this was in the best interests of the person. The manager explained that the GP, a Psychiatrist and a relative had all agreed for the medicine to be given hidden in a drink, however there was no written record or signed agreement available in the care plan. When we returned to the home on 3rd February 2010, we saw a prescription for an antibiotic, dated 2nd February 2010, pinned to the cork board in the office. Records showed that the GP had visited the previous morning and prescribed the antibiotic. The manager was unable to give a satisfactory explanation as to why the home had not obtained the antibiotic. It is unacceptable that someone should have to wait over 24 hours to receive their antibiotics, and places them at risk of harm. Care Homes for Older People Page 16 of 37 Evidence: We found that staff were not aware of the medication they were giving to people. For example, we spoke to two carers about the medicines prescribed for one person. They were not aware what the medication was prescribed for and one carer commented to be honest I dont know. We saw a folder which contained all the necessary patient information leaflets for each medication. We were shown another folder by the manager, which contained information about peoples prescribed medication. The manager explained that all staff are aware that there is a folder available, and could not understand why the staff did not know. This means that medication was being given to people by staff who were not aware of what the medication was for and were not aware of the availability of medication information. We saw that staff training on medication had been provided by the manager, who confirmed to us that she is not accredited to provide such training. Medication training should be delivered by an accredited training provider, so that people can be confident that staff have the skills and knowledge they need to administer medication safely. Because the management of medication places people living at the home at high risk of harm, we have referred this to the Local Authority under their procedures for protecting vulnerable adults. We are particularly concerned about these shortfalls, as we have previously issued a Statutory Requirement Notice in respect of the management of medication. Also, on 4 January 2010, we wrote to the registered provider and the manager stressing the importance of compliance with Regulations. We are serving another Statutory Requirement Notice following this inspection. Care plans emphasise the importance of protecting peoples privacy and dignity, and we saw staff treating people kindly and respectfully throughout the inspection. However, the door of the downstairs toilet did not close fully into its rebate, and anyone using the toilet would be visible to people using the corridor. We have written to the registered provider, requiring him to ensure that peoples privacy and dignity are respected and promoted at all times. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to a range of activities which meet their individual wishes and choices. The home provides a balanced diet of home-cooked food which is varied and nutritious. Evidence: We saw that care plans included details about peoples lives before they moved to Cleeve House, and clearly described their likes and dislikes, and any social or leisure interests. In our surveys, people told us that the home always arranges activities for them to take part in if they wish. The manager told us that she is currently working hard to improve the range of activities within the home. We saw that a lounge has been made into a sensory room, with sensory and activity equipment such as reminiscence packs, painting equipment, soft toys, scented modelling dough, and a bubble lamp. Paintings and salt dough models made by people living at the home were displayed in the room. The records kept by the home showed that the variety and frequency of activities has improved recently. The manager told us that some people enjoy helping with tasks Care Homes for Older People Page 18 of 37 Evidence: within the home, such as dusting, folding laundry and preparing vegetables. This helps people to feel that they are part of the life of the home. Relatives told us that they are always made welcome whenever they visit. We spoke to people about the food, and everyone told us that they enjoy the meals provided at the home. One person said if there was a gold star to be given, Id give it for the food. The menus are rotated on a four weekly basis and were seen to provide a nutritionally balanced diet. Lunch on the day of the inspection was beef and mushroom pie or roast chicken breast with carrots, cauliflower and mashed potato, followed by apple crumble and custard. Supper always includes a cooked option, such as a jacket potato or sausage rolls, as well as soup and sandwiches. Hot drinks are served during day, with biscuits and homemade cake. The cook showed that she understands how to meet the nutritional needs of people with diabetes, and other special dietary requirements such as a gluten free diet. People can eat whatever they like for breakfast, and we saw that one person was having breakfast in their bedroom at 10.00 and another in the dining room at 10.40. Breakfast was well presented and looked appetising. The cook told us that she asks people during the morning what they would like for lunch. The menu is written on a chalkboard in the hall. We saw staff supporting one person to eat. The staff member sat next to the person, and supported them discreetly and sensitively. Care Homes for Older People Page 19 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot always be confident that any concerns or complaints will be listened to and dealt with quickly and effectively. Staff know how to protect people from the risk of abuse, but are not always aware of circumstances where people could be at risk of neglect. Evidence: The home has a detailed complaints procedure, which is given to everyone who moves into Cleeve House. We saw that the complaints procedure is also displayed by the front door. In our surveys, people told us that they know who to speak to if they have any concerns. The complaints procedure did not include information about how complaints can be referred to the Commission. We looked at the homes records of complaints received and saw that none had been recorded. However, the manager told us about a recent complaint which had been reported to the registered provider. There was no written information about the complaint and how it had been resolved. The provider has subsequently told us that the issue had been dealt with, but that he had not considered it to be a complaint, and had therefore not recorded it as such. We, the Commission, have not received any complaints about the home since the last inspection. Care Homes for Older People Page 20 of 37 Evidence: One person told us that they would feel comfortable raising any concerns with staff at the home, but did not feel confident that they would be resolved promptly. This was because they had raised a concern and it had taken several reminders before it was sorted out. One of the ways in which the home can protect people who live there is by ensuring that staff know about their role in preventing abuse or neglect. Although records showed that staff had been trained, this training had been provided by the manager, who told us that she had not received any training in this area herself for the past two and a half years. However, staff knew how to report any concerns about possible abuse or neglect. Whilst staff know how to report their concerns about possible abuse or neglect, we were concerned that they had failed to recognise potential neglect in some circumstances. We have talked about these issues in the report in the section on Health and Personal Care. Staff recruitment procedures at the home help to protect people by making sure that only suitable staff are employed. Care Homes for Older People Page 21 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a very comfortable and homely place for people to live. Infection control measures need to be improved, so that the risk of cross-contamination is reduced. 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. Since the last inspection, most of the rooms have been redecorated, and some of the communal rooms have been totally refurbished. The TV lounge is a pleasant room with armchairs and a leather sofa. The dining room is a spacious and airy room, with tables spaced so that everyone has plenty of room to eat in comfort. There is 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. People are encouraged to personalise their bedrooms with their own ornaments, pictures and any furniture they wish to bring with them. We saw that the bedrooms were clean and people told us that the home is always clean and fresh. Care Homes for Older People Page 22 of 37 Evidence: There is a large garden with a well-kept patio area, and a covered gazebo with wooden garden furniture. There is a small lawn area and last year the manager told us that she had plans to involve people living at the home in planting vegetables, but this has not yet happened. 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. However, we saw that some toilets had no handwash, no paper towels, and no waste bin. Two toilets had no toilet roll holder and in one room the toilet brush was visibly dirty. The manager explained that toilet roll holders had been bought but that the registered provider was planning to install them himself rather than pay for someone to come in to do the task. She also showed us an entry in the staff communication book from the cleaner asking the registered provider for new toilet brushes. She explained that there had sometimes been delays in replacing small care items. The provider has subsequently informed us that a better system is now in place for ordering small care items. Care Homes for Older People Page 23 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are kind and caring, and have a good level of knowledge and skill. The homes recruitment procedures protect people by making sure that only suitable staff are employed. Evidence: People were very positive about the staff at the home. Comments included very friendly, do their very best and theyre kind and always work hard. Staff demonstrated a good knowledge of each persons individual needs and preferences. We spoke to people living at the home and their relatives, and they told us that the home is occasionally short-staffed. One person said this affects the level of care, people have to wait. They told us that the previous weekend there were only two on, they seemed stressed, things were delayed a little. Staffing rotas showed that, on the Monday preceding the inspection, there were only two staff on duty for much of the afternoon and early evening. Records showed that five people living at the home need the support of two staff to mobilise. This means that there are times when there are no staff available to support other people. In the section on Health and Personal Care we have mentioned an incident where the lack of staff meant that someone was unable to have a bath. The rotas for subsequent days showed that only two staff were rostered for some afternoon and evening shifts, but Care Homes for Older People Page 24 of 37 Evidence: the provider assured us that these shifts were covered with extra staffing. We saw that there were higher staffing levels for the morning shifts, and the provider has since told us that staffing levels have been increased for the afternoon and evening shifts. One person told us that they appreciate the consistency of the staffing at the home. At the previous inspection, we had seen that recruitment is carried out safely, and that all the required checks are undertaken to make sure that only suitable staff are employed. We looked at the homes training records, and these showed that staff receive regular training in all the required areas, such as fire safety, moving and handling, and first aid. In the section on Health and Personal Care, we mentioned that training in medication administration and management was not being provided by an accredited training provider, as it should be. Care Homes for Older People Page 25 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager does not have sufficient time or support to carry out all her duties, and this has a negative impact on people living at the home. People appreciate the service that they receive, but they cannot be confident that the homes procedures safeguard and promote their health and welfare at all times. Evidence: Throughout the inspection, the manager showed that she genuinely cares for the people who live at Cleeve House. However, there are serious concerns about some aspects of the home, and these are the legal responsibility of both the manager and the registered provider, Cleeve House Care Ltd. There is no deputy manager, nor any administration staff, so the manager has to manage the home, with little support, whilst working as a carer for much of the time. The rota for the week of the inspection showed that her working hours were 54 hours for the week, of which approximately half were worked as a carer. She told us that she does not have protected management time, and that often her management Care Homes for Older People Page 26 of 37 Evidence: duties have to wait, as she is needed to work as a carer. There was no evidence that the manager has received any supervision or regular training to help her keep up to date with current good practice. The manager told us that she is currently undertaking some training in dementia care, but that she has had to pay half the cost of this herself. She told us that she is not aware of any training budget, but has to ask Mr Mills, the responsible individual for Cleeve House Care Ltd, whenever training is required. The manager told us that she has nobody to whom she can delegate work such as reviewing care plans and auditing medication. It was obvious by talking to the manager and staff, and by looking at the care records, staff files and other records within the home, that the manager is having to carry out more roles than one person can reasonably be expected to fulfil. Throughout the report, we have identified shortfalls, some of them serious, and part of the reason for these is undoubtedly that no one person, however committed and conscientious, can carry the workload which is expected of this manager. Some aspects of the management of the home appear to involve the manager in more work than is necessary. For example, previously the cook bought food monthly from the local cash and carry outlet. Mr Mills has started a new system, whereby the cook writes a weekly shopping list. The manager explained that the cook does not know how to use the computer, so the manager has to type the list out and email it to Mr Mills, who then does an online supermarket shop for delivery to the home. The provider has since told us that the ordering system has now been simplified. Although the home does not usually take responsibility for peoples personal money, we saw that an envelope containing cash was in the medication cupboard. The manager explained that this was personal money for a person living at the home whose relative was going away and had left the money for any expenses. Writing on the envelope stated that it had originally contained 100 pounds, and that two payments totalling 50 pounds had been taken out, therefore there should have been 50 pounds left in the envelope. We counted the money and there was 157 pounds and 52 pence in the envelope. There was no other record to show where this money had come from and how it had been spent. This is not an acceptable way to manage peoples personal money. It should not have been kept in the medication cupboard and there should have been accurate records of any expenditure. At the previous inspection almost a year ago, we were told that the home was in the process of carrying out quality assurance surveys, the results of which would be used Care Homes for Older People Page 27 of 37 Evidence: to make improvements to the service. At this inspection, the manager told us that the surveys were being analysed. It is disappointing that there has been so little progress in finding out peoples views of the service and in using those views to ensure that the home is run in peoples best interests. We saw records which showed that Mr Mills visits the home regularly, and provides written reports of his visits. The manager completed the AQAA and sent it to us when we asked for it. It included detailed information about the home, but did not show much insight into some of the issues identified at the inspection as being of serious concern, such as the management of medication. Throughout the report, we have identified areas of concern about peoples health and safety. We will be making specific requirements to ensure that the home addresses these issues. Care Homes for Older People Page 28 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 (1) and (2) You must ensure 12/04/2010 that, where people are at risk of pressure sores, care plans are in place, and are sufficiently detailed to enable staff to understand how to prevent the development of pressure sores. This is so that the risk of people developing pressure sores is minimised as far as possible. 2 8 12 (1) You must ensure that, where people are at risk of needlestick injuries, an effective procedure is in place so that staff know what to do in the event of such an injury. This is so that people are not at risk of harm or injury. 12/04/2010 Care Homes for Older People Page 30 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 8 13 (1)(b) You must ensure that people have prompt access to treatment and advice from health care professionals. This is so that people can be confident that their health needs will be met. 04/03/2010 4 8 12 (1) You must ensure that the numbers of staff are appropriate to the assessed needs of people living at the home, taking into account their individual health and personal care needs, at all times. This is so that people can be confident that their needs will be met in a timely manner, and to ensure that they are not at risk of their needs not being met. 04/03/2010 5 9 12 (1) You must ensure that 12/04/2010 prescribed medication is in stock for all persons living at the home. This is so that people receive their medication as prescribed. 6 9 13 (2) You must ensure that recordings are made of all medications received into the Home. 16/03/2010 Care Homes for Older People Page 31 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 7 9 13 (2) You must ensure that recordings are made of any medications that are left over from previous medicating cycles. This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 8 9 13 (2) Where medication is 12/04/2010 being administered covertly, you must ensure that the care plan reflects the persons assessed needs and any agreements to administer medicines in food or drink are clearly documented, in accordance with the Mental Capacity Act 2005. This is to ensure that peoples rights are protected. 9 9 13 (2) You must make 16/03/2010 arrangements to ensure that 16/03/2010 Care Homes for Older People Page 32 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action medication administration records are accurately maintained. This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 10 9 13 (2) You must ensure that arrangements are in place for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This requirement is subject to a Statutory Requirement Notice. This is so that people can be confident that medication is managed safely. 11 9 13 (2) You must make 16/03/2010 arrangements to ensure that all medication is administered as directed by the prescriber. This requirement is subject to a Statutory Requirement Notice. 16/03/2010 Care Homes for Older People Page 33 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people can be confident that they will receive their medication as prescribed. 12 10 12 (4) You must ensure that peoples privacy and dignity is respected and promoted at all times. This is so that people can be confident that their right to privacy is respected. 13 27 18 (1)(a) You must ensure that staff are suitably qualified, experienced and competent to safely administer medication, before they administer medication to people in the service. This is in order to ensure that people who live in the service are protected from harm. 14 31 10 The registered provider must put an effective system in place to ensure that the manager receives the support and training she requires in order to fulfil her duties to the required standard. 12/04/2010 12/04/2010 04/03/2010 Care Homes for Older People Page 34 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people can be confident that the manager has the skills and knowledge to meet their needs. 15 31 10 The registered provider 12/04/2010 must put an effective system in place to ensure that the manager is given enough time to carry out her management duties. This is so that the manager has enough time to ensure that peoples needs are fully met and that their health and welfare are protected and promoted at all times. 16 35 17 (2) You must ensure that accurate records are kept of any money held in safekeeping, and that these records are available for inspection. This is to make sure that peoples financial interests are safeguarded. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 12/04/2010 1 2 1 16 You should ensure that the Service User Guide is updated so that it contains accurate information about the service. You should ensure that the complaints procedure includes Page 35 of 37 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations information that people can contact the Commission at any stage of the process. This is so that peoples rights are protected. 3 18 You should ensure that staff receive regular training in the protection of vulnerable adults. This is so that they are aware of current good practice, which will help them to protect the people who live at the home. Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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