Inspection on 22/02/07 for Cleeve Lodge

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Lodge 06/05/08

Cleeve Lodge 20/07/07

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

CARE HOMES FOR OLDER PEOPLE Cleeve Lodge Cleeve Lodge Close Downend South Glos BS16 6AQ Lead Inspector Grace Agu Key Unannounced Inspection 8th January 2007 09:15 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 Lodge DS0000068293.V321841.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 Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Lodge Address Cleeve Lodge Close Downend South Glos BS16 6AQ 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) 0117 970 2273 0117 956 6027 cleeve@lodge87.fsnet.co.uk Shields Care Limited Mrs Lesley Caron Maddox Mr Colin Maddox Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (3) of places Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 Up to 3 persons with Physical Disabilities aged 45 years and over Date of last inspection Brief Description of the Service: Cleeve Lodge is a family run care home opened in 1993 to provide care and accommodation for 30 older people and 3 people with disabilities aged 45 and over. The property is a listed building, dating back to the 18th Century, which has been carefully restored and maintained in keeping with the period of the house. The home is located in the residential area of Downend, South Gloucestershire, close to the border of the City of Bristol. Local shops and other community facilities are close to the home and it is within easy reach of motorway connections. The homes 30 bedrooms (3 of double size) are situated on three floors and are equipped with TVs, emergency call systems and en-suite facilities. There are gardens and lawns to the front and side of the property. Fees range from £385-£510 weekly Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over eight hours and was undertaken to review the requirements made at the last inspection and to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection before the new owners took over three requirements were made, it was pleasing to note that the home had made efforts to ensure that the requirements were met. Six residents, nine staff members and one relative were spoken with at the inspection. A number of records were viewed and a tour of the building was undertaken. What the service does well: Whilst new owners had purchased the home, the registered managers who previously owned the home remain in post to ensure continuity in the management of the home. Residents and staff spoken with said that this has made a big difference to the home. One of the registered managers met on the day of inspection stated that they are pleased that the changeover between owners has been managed well and the new provider have been able to continue the previous good relationship between staff and residents. One resident said, “ The new owner comes to see us several times a week, that’s very good.” Residents, staff and the relative met on the day were very complimentary of the way the take over was handled. The manager said at a discussion that the home is renowned for staff retention; the average length of time that staff stayed at the home was eleven years. One staff was recognised and rewarded for 10years service to the home on the day of inspection. When a group of staff were asked the reason for staff retention, they all responded in unison that it was good atmosphere and teamwork. The manager stated that the home has an open door policy that enables the residents, relatives and staff to talk to the management about any concerns at any time. The home listens to the residents, their relatives and staff and involves them in the decision making process. The manager also stated that staff provide the residents with a person centred approach to their care without compromising their independence. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst reviewing medication, some medicine chart discrepancies were noted. The home must ensure that all hand written medication on the Medication Administration Record Sheet (MARS) is signed and dated. All medication not administered must not be signed for, and reasons for medication not administered must be properly recorded to prevent drug errors and to protect the residents. To provide adequate protection to the resident, risk assessment must be undertaken and consent obtained from a resident on self-medication. Residents would be protected from drug error if a medication was dispensed from the original packet from the pharmacy. It was noted whilst reviewing medication that the home had no Control drug register and the Control drugs were stored in a lose carry box. These were discussed with the manager requirements were made for these to be corrected. To ensure that residents’ medication is safe and the home is made less vulnerable, the medicine trolley must be secured on the wall. Staff working in the laundry must be trained on infection control and Control and Control of Substances Hazardous to Health to enable them to perform their duties effectively. The home must ensure that residents are assessed before admission and confirm in writing that they are able to meet the individual’s needs. During a discussion with three residents in the main lounge, they expressed their concern about the method of summoning assistance because there was no call bell in the lounge. One of the residents said “ the only problem we have here is that we have no call bell in the lounge to call for help if we need it, we have to yell to attract staff attention”. This issue was discussed with the manager and the inspection was given assurance that a call bell would be installed within days of the inspection. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 7 No requirement was made. The Commission for Social Care inspection was informed by the home that a call bell has now been installed in the main lounge. 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 Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The admission process is well managed however the home fails to provide residents with a Service Users Guide to give residents and their representatives clear information regarding the service. EVIDENCE: The home has a Statement of Purpose under the new providers. This document contains required information in terms of admission procedure, category of residents, staff training and social activities. The home has no Service Users Guide to provide prospective and existing residents with information about the services provided at the home. However the manager stated that the new owners plan to put one in place in future. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 10 Whilst there was no preadmission record seen in the recently admitted resident’s file, the manager stated that one of the managers would visit the resident either in their home or in hospital to assess the homes suitability for the individual to receive care at the home. The individual is also reassessed on admission before a care plan is developed with the individual and/or their representative based on the needs identified. The home must confirm in writing to the resident that it is able to meet the needs of the resident in terms of health and welfare One new resident spoken with said that she was made welcomed when she arrived and that they knew about the home before admission. The Statement of Purpose confirm that newly admitted residents have one month trial period during which they can change their mind. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10.11 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ are looked after well in respect of their health and personal care needs. Care plans are in place to support staff in meeting the needs of the residents. However the home needs to review medication administration procedures to ensure safety of the residents. EVIDENCE: Whilst the home has changed ownership, most of the residents have been living in the home for many years. The last inspection before the change over evidenced that the residents’ physical emotional and social needs were assessed and care plans were in place describing how the needs were being met. There was also evidence of assessed potential risks to the residents and plans were in place to minimise the risks. This inspection showed no change from the above. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 12 Residents spoken with stated that staff respected their privacy and treated them with respect. One resident stated, “ I like it here, staff are respectful, I get up and retire when I like usually 8 am. They answer when I ring the bell.” The inspector noted care staff knocking at the residents’ doors and waiting for an answer before going in to attend to the residents in their bedrooms. A group of staff spoken with in the dinning area confirmed that they are able to meet the needs of the residents through reviewing the care plans, regular hand over and discussion with the residents. The staff member spoken with demonstrated knowledge of caring for the dying and the importance of keeping information about the residents confidential. The two residents care files viewed evidenced that the General Practitioner and other health professionals were involved in the management of the residents care. The procedure for the administration, storage and disposal of medication was reviewed and showed that there were unsafe practices at the home. It was also noted that there was no risk assessment and written consent for three residents who had chosen to self medicate to ensure adequate protection. Large quantities of loose white tablets were noted in a broken envelope in the medicine trolley compartment. There was no label on the envelope however the deputy manager said that they were ‘Paracetamol’ but that the original box was broken. The medicine trolley had no detachable chain to secure it to the wall to protect residents’ medication. Control drug for one resident was not appropriately stored and there was no control drug book to record the drug and ensure accountability. The dose on the Controlled drug was changed on the Medication Administration Record Sheet (hand written over) and did not correspond with the printed instructions on the Controlled drug box from the dispensing pharmacy. The deputy manager said that this was changed by a health professional that reviewed the medication a day before the inspection. The manager contacted the doctor surgery and the pharmacy to remedy the discrepancies before the inspection was concluded to protect the resident. Staff interviewed were aware of policies and procedures for dealing with a dying resident and at the time of death. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 13 Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to maintain contact with families, friends and local communities. Residents’ activities are structured and meaningful. However the home needs to provide residents with choice of meals. EVIDENCE: The visitors’ book showed that the relatives and representatives regularly visit the residents. Residents spoken with confirmed that they had regular visitors. One resident spoken with said that the relatives visit every weekend and are in regular contact on the telephone. The inspector noted whilst walking about that the home has a portable phone installed that the residents and visitors could use. Some residents also have private phones in their rooms. The home’s activities programme for the residents was reviewed. It was noted that the home ensures that regular activities are provided to the residents to include Bingo, card making, flower arranging, board games, a variety of quizzes, puzzles, films, and piano sing along. Activities are diarised and the Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 15 names of resident who attended are recorded. External entertainment is also arranged. The home inherited a minibus from the previous owners and the manager stated that mini bus trips to places of interest are arranged. Places recently visited include, country pubs, and garden centres. At a discussion, the manager stated that care staff interact with the residents on personal basis whist providing personal care and specifically for residents who choose to stay in their rooms or unable to participate in activities due to their medical condition. A six weeks menu was reviewed and there was one main choice of meals at lunch times. The menu showed that specialist meals (Diabetic) are also provided. The meal noted at lunch -time on the day of inspection looked nutritious and well balanced. The Home Manager stated that alternatives are provided if residents are not happy with what was on the menu. Whilst some residents were satisfied with the menu and one of them confirmed that “the food is very good, I can eat anything. They do diabetic as well. If you don’t like the menu you can have an alternative.” However, two of the residents consulted on the day of inspection had different views about the food provided at the Home. One resident stated “We don’t have a choice at lunch, we don’t know what we are supposed to have today”. Another resident stated “it would be good if we had a choice in the afternoon”. The views of the minority of residents were discussed with the manager and it was recommended that the menus be reviewed to give the residents a wider variety at lunchtime and to accommodate the views of the above residents. Staff were noted assisting residents and those who were unable to feed themselves were fed in a sensitive and dignified manner. The kitchen was found clean and the manager stated that there were no risk assessments in relation to various areas of the kitchen and hazardous equipments, however they would ensure that there is one in place. A record of fridge and freezer temperatures and food probing were also noted up to date. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that the home is able to protect them from harm and abuse. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the home, which means people will know how to obtain the required information if they want to make a complaint. The document contains information about the Commission for Social Care inspection to enable the residents and their representatives to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. There was one recorded complaints received, this was in relation to a resident calling for attention however was answered as urgently as the individual had expected. This complaint was investigated and well documented with comprehensive notes. Records show that the complaint had been dealt with efficiently and effectively and that the residents were pleased with the outcome of the investigation. Measures were put in place to prevent the issue from happening again. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 17 Evidence from the most recently employed staff members’ files showed that a staff member recruited recently had only one reference in the file. The manager explained that the home had obtained a satisfactory verbal reference but had not recorded it. There is Criminal Record Bureau (CRB) Enhanced disclosure in the staff member’s file. Whilst no requirement was issued, the manager was reminded of the importance of ensuring that appropriate, recruitment documentation is in place before commencement of employment. The home has a policy in the Protection of Vulnerable Adults from Abuse. The manager stated that Abuse policy is included in the induction training. However a review of staff training evidenced that staff have not attended in-depth training on this very important topic. It was agreed that that the home should contact the South Gloucestershire Council to book places for staff to attend comprehensive training to provide adequate protection to the residents. It was also agreed with the manager that the home contact the South Gloucestershire Council for a copy of ‘NO Secrets’ Guidance on the Protection of Vulnerable Adults to ensure that staff are aware of the protocol to follow in the event of abuse. The Commission was contacted and informed by the manager that this document is now in place. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a pleasant, safe and homely environment with a good standard of hygiene. EVIDENCE: The home provides a comfortable environment that is suited to the present category of residents, is able to meet their needs and is accessible to the community facilities The home has spacious and well-decorated lounges and provides a relaxing environment for the residents. The residents were found sitting in the communal areas and appeared relaxed in their homely environment. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 19 The home was found clean, warm, well lit, beautifully decorated and free from unpleasant odours. All the bedrooms seen were clean, tidy, colour coordinated and homely. Residents met in their bed rooms said that they were comfortable and the rooms provided them with warmth and sense of belonging. Toilets and bathrooms meet the needs of current residents and are fitted with grab rails. The corridors have handrails to support optimum mobility for the residents. It was pleasing to note the requirement made at the last inspection in relation to covering the radiators for residents’ safety had been met. The clinical waste is correctly disposed of to prevent the spread of infections. There is an infection control policy in place. One resident spoken with stated, “I like it here the Home is always clean lovely”. Residents spoken with stated that they “felt safe at the home”. The laundry room was noted to be clean and tidy and has suitable equipment to wash, dry and press the residents’ clothes. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a good, warm relationship with competent staff. The Home’s recruitment procedure offers protection to residents. There is adequate numbers of staff to meet the needs of the residents. EVIDENCE: On the day of inspection there were thirty -one residents at the home. The rota showed that there were four care staff in the morning, three staff in the afternoon and early evening and two waking night staff. The registered manager stated that the numbers of care staff on duty adequately meets the care needs of the residents. In addition to the above, the manager stated that occasionally an extra care staff is provided either for the morning or the afternoon shift to support the team on the floors in meeting the needs of the residents. This practice also applies on weekends. One of the registered managers is on duty daily as well as the deputy manager, this provides an added advantage to the staffing level and would enable the home to provide cover for annual leave and sickness. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 21 Other staff members employed at the home includes domestic staff, cook and a maintenance person. The home’s recruitment policy contained information that offers safeguards to residents. Residents spoken with said that they felt safe at the home. The issue highlighted in relation to a recently recruited staff had been discussed under standard 17. Staff interviewed demonstrated competency in their jobs, and are aware of their responsibilities, including Terms and Conditions of their employment. New staff have received induction. The manager stated that all newly appointed staff are issued an induction pack and that the staff member continues with the process until they are competent to work independently with residents. A review of records showed that staff members have not attended POVA training. This was previously discussed in Standard 18. The training record showed that five care have achieved National Vocational Qualification at level 2 and six care staff are currently undertaking National Vocational Qualification at level 2. Other training undertaken include First Aid, medication, food hygiene, Moving and Handling, health and safety. Residents and their relatives made positive comments about the home and the services provided. One resident told the inspector that staff are very good, caring and that they were well trained. One comment care from a relative states “It is my opinion that the management and staff have together created a homely and friendly environment at Cleeve Lodge with a level of care that is cheerfully provided at all times”. Another comment card read “ Mum has been in Cleeve Lodge since February 06. I am very happy with the home, the staff are always helpful and friendly, nothing is too much trouble and the home is always spotlessly clean. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and Staff have received regular supervision in relation to their role. However some of the home’s health and safety practices do not fully protect the residents, staff and visitors. EVIDENCE: Mr Colin Maddox and Mrs Lesley Maddox previously owned the home and have been registered managers of the home before it was sold to the present owners in November 2006. The couple continue to manage the home following agreement with the present provider. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 23 Residents and staff spoken with said they were pleased with this arrangement because it had provided them with continuity and stability. The registered managers have achieved Registered Managers Award and are both National Vocational Qualification (NVQ) Assessors. The home also employs a deputy manager who also holds an NVQ at level 3. The manager stated that the deputy manager is considering undertaking the Registered Managers Award. In relation to health and safety evidence showed that staff have attended fire drills. The Fire safety log -book was well maintained. All health and safety checks were up to date. There is a service record of the lifts, hoists, bath hoists and portable appliance tests (PAT) of all electrical appliances. The registered manager is aware and would ensure that the individual working in the laundry receive training on infection control to ensure that residents are adequately protected. However it was noted that generic risk assessments have not been undertaken to ensure adequate protection of residents. Specific areas of concern include, the kitchen, laundry, residents’ bedrooms and other areas the residents have access to. A requirement has been made for the home to undertake the risk assessments for residents’ safety. Accidents to residents were recorded. It was agreed that accidents need to be reviewed following falls and where appropriate care plans and risk assessments reviewed to ensure that the individual is adequately protected and to prevent further occurrences. The new provider has recently undertaken an audit to monitor the quality of the services provided for the residents. These include, residents and relatives questionnaires. On the recent questionnaires seen, areas monitored included, care of residents, catering, house keeping, and administration. The result of the audit will enable the home to identify any deficiencies and ensure that they are addressed. Other ways used to audit the service are, reviewing the Care plans; social worker reviews, observing staff interaction with residents. Staff meeting and resident/ relative meetings provide a forum for discussion in relation to service improvement. The Commission for Social Care Inspection has received reports of monthly required visits from the registered provider since registration. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 24 Various Policies and procedures were in place, relevant and updated. Residents, staff and relatives made positive comments about the manager and expressed satisfaction with the overall services and management of the home. One resident stated, “I am happy here, the manager and staff are good”. One relative stated I am satisfied with the care of my relatives” Staff supervision records were checked and some staff members have received regular supervision to enable them to express areas of concern in relation to resident’ care and further reflect on their work. Regular supervision is needed to support staff to carry out their responsibilities in providing good care for the residents. Residents’ monies checked evidenced that the record is up to date, the amount stored in the safe corresponded with the balance recorded in the book. Residents’ information was appropriately stored and locked away. Cleeve Lodge DS0000068293.V321841.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 2 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 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 3 3 X 3 3 3 2 Cleeve Lodge DS0000068293.V321841.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 OP2 Regulation 5 Requirement “The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide” Ensure that there is a Service users Guide in place “The registered person shall make arrangement for the recording, handling, safe keeping, safe administration and disposal of medicines received at the care home”. (a) Ensure that the medicine trolley is changed to the wall when not in use. (b) All medication written on the MARS must correspond with the original label on the box supplied by the pharmacist. (c) Purchase a Control Drug registered and ensure that all medicines are transferred to the book. (d) Residents on self medication must be risk assessed and consent obtained. Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 27 Timescale for action 22/06/07 2 OP9 13 22/03/07 3 OP38 13 “The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated” Undertake a generic risk assessment at the home. 22/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations Review the menu to give the residents more variety at lunch time in line with some residents comments Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. Extracts may not be used or reproduced without the express permission of CSCI Cleeve Lodge DS0000068293.V321841.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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