Inspection on 18/03/06 for Clevedon Court Nursing Home

This inspection was carried out on 18th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Clevedon Court Nursing Home 30/12/08

Clevedon Court Nursing Home 11/01/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Clevedon Court Nursing Home 32 Dial Hill Road Clevedon North Somerset BS21 7HN Lead Inspector Juanita Glass Unannounced Inspection 18th March 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 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. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clevedon Court Nursing Home Address 32 Dial Hill Road Clevedon North Somerset BS21 7HN 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) 01275 872694 01275 342444 Clevedon Court Nursing Home Ltd Mrs Gaynor Allen Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Manager must be a RN on Parts 1 or 12 of the NMC Manager May accommodate up to 35 persons aged 65 years and over requiring nursing care. May accommodate one person aged between 18-64 years of age with physical disabilities requiring nursing care. May accommodate up to 2 persons aged 65 yerars and over requiring personal care. Staffing notice 26th June 2000 applies Date of last inspection 22nd August 2005 Brief Description of the Service: processed in conjuction with an application to increase the number of registered places in the home. The home currently offers accommodation in 27 single and 4-shared rooms. None of these have en suite facilities, although all are fitted with a wash hand basin. There are a good range of communal lounge and dining areas. The rooms at the front of the building enjoy panoramic views over the town and bay. A passenger lift provides easy access to all areas of the home. There is a pleasant patio to the side of the property, and plenty of parking for visitors. Work has recently started to convert unused rooms on the top floor of the property to create a further 5 bedrooms with ensuite facilities. A ground floor extension will provide the necessary additional communal space. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very positive unannounced inspection; a review of resident and staff records was carried out however the focus was on the outcomes for the residents. During the six and a half hours spent in the home 10 residents and 2 visitors were spoken to they all had very high opinions of the level of care provided in the home. Staff were not formally interviewed but observed in their one to one rapport with the residents which was friendly, relaxed and showed respect and understanding of the residents needs. The general outcomes for residents were good and the staff behaved in a very professional and caring manner. What the service does well: What has improved since the last inspection? All the recommendations made at the last inspection concerning medication had been met, an audit of medication could be maintained and staff were signing when medication had been given and indicating why if omitted. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. 6 does not apply Residents’ needs are effectively assessed before they are admitted to the home. They are offered a chance to visit the home before admission. They and their families are given good information about the services offered at Clevedon Court. All residents had signed contracts or statements of terms and conditions. EVIDENCE: Care records reviewed evidenced that Mrs Allen visits prospective residents to carry out a full assessment of their needs, residents spoken to were unable to comment on their admission process, one visitor said the most important thing for her had been the open way in which she was welcomed and shown around the home, and the attitude of staff towards her at that time. Care records also showed that residents have signed contracts or a statement of terms and conditions with the home. These include the room, fees and any extra charges. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The standard of care documentation is good. Residents’ health and personal care needs are well met. There is a friendly atmosphere in the home, with a good rapport between residents and staff. EVIDENCE: Care records reviewed showed that there were care plans for individual identified needs, these provided staff with very clear guidance to enable them to meet the needs of the residents. Staff were not formally interviewed however they demonstrated an understanding of individual needs. The home is supported by a nurse specialist from the Primary Care trust who regularly reviews the health needs and medication of the residents. Residents spoken to during the inspection were relaxed, cheerful and had a friendly rapport with staff who they felt they could joke with and talk to. All residents, both those in the communal areas and those in their own rooms were neatly dressed and well groomed, one visitor commented on the care provided she said she visited everyday and could never fault any of the staff. Residents being nursed in bed had the relevant pressure relief and adequate fluids and charts to support the care they needed. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 10 Both relatives and residents said that the level of care provided was excellent, they said they were kept well informed by staff, one relative said they always felt welcomed by staff and could visit at any time. Residents spoken to said that staff were always respectful and respected their wishes staff were observed to have a friendly but respectful rapport with both the residents and their visitors. Staff were observed to knock on doors and to ask permission to enter rooms. It was also pleasant to hear staff saying please and thank you through out the day. Recommendations made at the last inspection concerning the recording of medication had been met and there were no errors noted, it was possible to carry out an audit of medication and all medication administered was signed for. It was noted a handwritten MAR sheet had not been signed by the person making the entry; this was discussed with the nurse in charge and a recommendation was made. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 The programme of planned and informal activities offered at Clevedon Court meets the needs and expectations of the residents. Family and friends are made welcome. Residents exercise choice over their lives. The food provided is of a particularly high standard. Residents actively enjoy the meals provided. EVIDENCE: The home continues to record residents likes and dislikes, and staff were observed to have a good understanding of individual preferences. Residents spoken to said they had plenty of opportunities to take part in an activity such as trips out or a board game in the afternoon with staff. One resident, when asked about activities said ‘well if you look over there dear you’ll see we’ve all been busy making our Easter bonnets, and if you stay long enough you can join me in a glass of sherry.’ Staff were observed talking with residents and asking if they wished to do something else. When asked about having control over her own life one resident said, ’well I wouldn’t stay here if I couldn’t have my own way.’ Residents were observed deciding whether to remain in one of the communal areas or their rooms, one of the residents said they could go to bed or get up when they wished and staff did not put pressure on them to do anything they did not want to do. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 12 The head cook discussed the menu and explained that all food was prepared from fresh ingredients, the menus are seasonal and the spring menu was being prepared, the cook had also consulted residents on the favourite food and a traditional theme was noted. The cook demonstrated an awareness of the nutritional needs of the elderly and in fact one residents commented on the fact that she had put on weight since moving in to the home. All the residents spoken to said that the food was excellent they all said that if they had a problem with the menu that day they could approach staff about an alternative. Lunch during the inspection was unhurried and staff were present to offer help when necessary. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The complaint procedure in the home is satisfactory. Staff demonstrate a good awareness of adult protection issues. EVIDENCE: There are comprehensive policies and procedures in place. A copy of the complaint procedure was displayed in each room. Residents and relatives consulted all confirmed that they knew how to use these procedures if the need should arise. Several commented that they felt comfortable raising informal concerns with Mrs Allen. Staff have received extensive training in adult protection issues. They demonstrated a good awareness of these. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Clevedon Court offers good all round accommodation. Residents have access to safe and comfortable bedrooms and communal areas. The standard of housekeeping is commendable. EVIDENCE: At this unannounced inspection, all areas of the home were found to be commendably clean and tidy. The housekeeping staff demonstrated a real pride in their work. One visitor said, ‘look at this room it’s always this clean and tidy whatever time I visit.’ Residents were also keen to praise the efforts of the laundry staff. Clothing and bedding was well presented. This was even evident with the work that is taking place as the front door was sealed and the backdoor the temporary main entrance. The residents have access to comfortable well-furnished bedrooms, which showed evidence of residents bringing in their personal possession. Residents were using all the communal areas during the inspection. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 The recruitment procedures do not meet current guidelines. A very comprehensive training programme equips staff with the skills and knowledge to meet the needs of the residents. EVIDENCE: Staff personnel records for the most recently appointed staff showed that POVA 1st confirmations had not been obtained before they commenced work in the home, this does not reflect the otherwise good practices demonstrated in the home and places residents at risk of abuse. Mr Allen and Mrs Allen continue to place a commendable emphasis on staff training and development. All staff have access to a good range of training opportunities both in the home, or outside. Personnel records showed that staff attend both mandatory and training specific to the needs of the residents and qualified staff are encouraged to maintain their personal develop. One relative said she had no doubt in her mind that staff in the home were well trained as they demonstrated an understanding of her relatives needs. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 36 and 38 The manager adopts an open and approachable ethos in the running of the home. Staff are appropriately supervised and receive a good induction. Health and safety in the home is satisfactory. EVIDENCE: Both residents and visitors spoken to said that they felt at ease when talking with both Mrs Allen and Mr Allen, they said they could approach them at any time and felt their comments would be taken seriously, staff also said the home had an open door feel. Mrs Allen and her deputy have worked out a formal programme of supervision for staff. Staff records contained evidence of a comprehensive induction programme. A review of the health and safety in the home was satisfactory, the fire log showed that all the appropriate checks were being carried out, the generic risk Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 17 assessments in the home include the building works, and maintenance in the home is ongoing. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 4 STAFFING Standard No Score 27 3 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 3 Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 19 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 OP29 Regulation 19 (4) Requirement A POVA 1st confirmation must be obtained before a new member of staff is appointed. Timescale for action 18/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Handwritten MAR sheets need to be signed by the person making the entry. Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clevedon Court Nursing Home DS0000063638.V285843.R01.S.doc Version 5.1 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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