Inspection on 30/03/10 for Cleeve House

This inspection was carried out on 30th March 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cleeve House 28/01/10

Cleeve House 10/03/09

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Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2010.

Random inspection report Care homes for older people Name: Address: Cleeve House 49 Hornyold Road Malvern Worcestershire WR14 1QH zero star poor service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme 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 review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Morag Ross Date: 3 0 0 3 2 0 1 0 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): Name of registered manager (if applicable) Mrs Breda Anne Goulding Type of registration: Number of places registered: Conditions of registration: Category(ies) : Cleeve House Care Ltd care home 16 Number of places (if applicable): Under 65 Over 65 16 old age, not falling within any other category Conditions of registration: 0 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 Care Homes for Older People Page 2 of 9 Brief description of the care home 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. Care Homes for Older People Page 3 of 9 What we found: We saw that all medication was stored securely and neatly which means that medication is safe and therefore the people who live in the service are protected from harm. We looked at the Medication Administration Record (MAR) charts and overall found that they were well documented with a signature for administration or a reason was recorded if medication was not given. We saw that the times of administering medicines were clearly highlighted on the MAR charts. This ensured that staff knew when to give medicines. For example we looked at peoples MAR charts and found that the records were clear and easy to follow. The Manager informed us that regular checks are also made on the medicine records and we were shown completed audits and checks made on peoples medication to ensure that they are correct and up to date. This means that there are arrangements in place to ensure that medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. We found that other medication records were generally up to date. For example, we saw current records for the receipt and disposal of medication. The date of opening of boxes and bottles of medicines were usually recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication. We found that counts and checks made on medication were accurate, which showed that people who live in the service were being given medication as prescribed by a medical practitioner. Information about peoples medicines were generally recorded in their care plans. For example we looked at the care plan for a person who chose to administer their own insulin with help from staff. The care plan included a completed risk assessment to ensure the person was safe from harm. What the care home does well: 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 set out on page 2. Care Homes for Older People Page 4 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ 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, Regulations 2001 and the National Minimum Standards. 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, 12/04/2010 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. 3 8 12 (1) You must ensure that the 04/03/2010 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 Care Homes for Older People Page 5 of 9 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action will be met in a timely manner, and to ensure that they are not at risk of their needs not being met. 4 8 13 (1)(b) You must ensure that 04/03/2010 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. 5 9 13 (2) You must ensure that 16/03/2010 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. 6 10 12 (4) You must ensure that 04/03/2010 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. 7 31 10 The registered provider must 12/04/2010 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 Care Homes for Older People Page 6 of 9 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action that peoples needs are fully met and that their health and welfare are protected and promoted at all times. 8 31 10 The registered provider must 12/04/2010 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. This is so that people can be confident that the manager has the skills and knowledge to meet their needs. 9 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. 12/04/2010 Care Homes for Older People Page 7 of 9 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, 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 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 Care Homes for Older People Page 8 of 9 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial 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. 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