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Inspection on 22/11/06 for Cleveland House Nursing Home

Also see our care home review for Cleveland House Nursing Home for more information

This inspection was carried out on 22nd November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All service users are appropriately assessed prior to admission to ensure that there needs can be met. Care plans set out the needs of the service users so that staff know what care needs to be delivered and the way in which the service user prefers their care to be delivered. Appropriate activities are arranged for service users to participate in if they wish to. The food served is nutritious, of a good standard and a choice is available. Staff are well trained and are deployed in such numbers to meet the needs of the service users. Good quality assurance systems are in place.

What has improved since the last inspection?

Care documentation is now fully completed and signed. Allergies to medicines are now recorded on medication administration record sheets and care plans.

What the care home could do better:

The home is maintaining good standards of care .

CARE HOMES FOR OLDER PEOPLE Cleveland House Nursing Home 2 Cleveland Road Edgerton Huddersfield West Yorkshire HD1 4PN Lead Inspector Helen Battle Key Unannounced Inspection 22nd November 2006 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 Cleveland House Nursing Home DS0000001112.V314061.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. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleveland House Nursing Home Address 2 Cleveland Road Edgerton Huddersfield West Yorkshire HD1 4PN 01484 512323 01484 548043 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) www.bupa.co.uk BUPA Care Homes (GL) Ltd Ms Joan Walton Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (5), Terminally ill (5) of places Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user under 65 years of age category LD 8th December 2005 Date of last inspection Brief Description of the Service: Cleveland House provides personal care and nursing for up to 45 elderly people. The home is a large stone built, converted residence with two new purpose built extensions. It is approximately half a mile from Marsh and 1 mile from Lindley with all their local amenities. Huddersfield centre is about 2 miles away with the bus stop at the end of the road. There are spacious gardens for service users to use and there is ample car parking. The Provider informed the Commission for Social Care Inspection on the 25.10.06 that the fees range from £354.00 to £595.00 per week. There are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection a visit to the home took place. The inspector, Helen Battle, visited the home unannounced from 09.15rs to 16.30hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the home’s policies were looked at, and so were the rooms and garden. Four members of staff were spoken with, along with the manager. Seven service users and five relatives were spoken with. The manager had been asked to complete a pre-inspection questionnaire. This was returned to the Commission prior to the visit taking place. Comment cards were sent to service users, their relatives, visiting professionals and GPs. Three GP surveys were returned. Two of these were positive stating that Cleveland House provides a “very high standard of clinical and personal care, to be commended.” Four relatives returned surveys. Two were very positive, one contained negative answers, however there were no explanations for these answers. One stated that they had had cause to complain to the provider and that things had improved as a result of this. Six service user surveys were returned, all were positive. What the service does well: All service users are appropriately assessed prior to admission to ensure that there needs can be met. Care plans set out the needs of the service users so that staff know what care needs to be delivered and the way in which the service user prefers their care to be delivered. Appropriate activities are arranged for service users to participate in if they wish to. The food served is nutritious, of a good standard and a choice is available. Staff are well trained and are deployed in such numbers to meet the needs of the service users. Good quality assurance systems are in place. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to moving into the home to ensure their needs can be met. Cleveland House does not provide intermediate care. EVIDENCE: The manager said that admissions are not made to the home until a full assessment has been done to find out what the person needs. The records show that the home then confirms that they can meet the needs of the individual through the service they deliver, as detailed in the statement of purpose. The records show that assessments are conducted appropriately and have involved the family members or the representative of the person wanting to move into the home. Where the assessment has been undertaken through the Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 9 local authority care management arrangements, the manager obtains a summary of the assessment and a copy of the plan. The manager said that the home does not provide intermediate care. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The care plans set out the needs of people, and the actions the staff are to take to meet these needs. Health care needs are assessed and recorded. The systems for the safe administration of medication are satisfactory and the systems protect the best interests of people living at the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users have written care plans that have recently been updated, giving details of how the staff are to meet the health, personal and social care needs people. The plans also include risk assessments. The manager and staff make sure that each person’s plan is reviewed monthly and if the person is willing and capable, they are asked to get involved in the Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 11 review. Family members can also take part if agreed by the person. There is evidence to show that the plans are updated and the necessary action taken to respond to any changes. A person living in the home said that they are supported to access local healthcare services, and any contact such as this is recorded in people’s care plans and daily records. People living at the home said that they have the choice to shower or bath, and that they are supported to be as independent as possible when washing and bathing. The records show that the arrangements for health and personal care ensure that service user’s privacy and dignity are respected, with the staff being heard to speak to people in respectful ways, and with service users themselves saying that the staff are kind, caring and very patient. The medication of four service users were checked and all found to tally with the records held. Oxygen is stored appropriately and systems are in place to ensure the safe storage and disposal of medication. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. There is a good range of activities from which service users may choose their particular lifestyles. The visiting arrangements are open. Choices are available to the service users in most area of their life. There is a good choice of nutritious meals served in the location of the service users’ choice. EVIDENCE: The routines of daily living and activities made available to service users were found to be flexible and service users said that they are varied to their needs, preferences and capabilities. The home currently has a daily activity schedule run by a dedicated activity organiser. This includes one to one and group activities, such as, artwork, baking, outside entertainers, glass colouring, quizzes, bingo, card making, flower arranging, film, music and movement, snakes and ladders. Three service users go out to church to worship every week and weekly communion is given at the home. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 13 Observations made on the day show that staff treat people politely and respect their individuality. One member of staff was observed to be assisting a service user to eat in a calm, relaxed manner with appropriate conversation. Staff call people by their preferred name or title. Service users spoke of friends and family being encouraged to visit at any time, and being made to feel very welcome. This was confirmed by visitors at the home at the time of this visit. Several people said that they have a varied, appealing and wholesome diet, which was suited to their individual requirements. The menus confirmed this. Meals were seen presented in an attractive manner and in pleasant surroundings. The records show that personal preferences in relation to food are gathered and recorded. People confirmed that the catering staff respond to these requests. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 14 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. The home’s policies and procedures for dealing with complaints or suspected abuse were found to be satisfactory with appropriate record keeping and training taking place. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure that is up to date, clearly written, and easy to understand. The complaints procedure is displayed in the entrance area of the home. Any complaints received are fully investigated and responses given to complainants within the timescale set out in the policy and procedure. Records of complaints received were seen during this visit. The policies and procedures regarding protection of people are satisfactory. Training of staff in the area of protection is periodically arranged by the home; the training records supported this. Further training is planned for staff in adult protection between January 2006 and March2006. People living at the home said that they are satisfied with the service provision, and that they feel safe. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 15 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, 26. The home is well maintained and people like the décor and surroundings. The home is kept clean. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the people. People said that the home is pleasant and comfortable. There was evidence in people’s rooms that they had been able to bring small personal items of furniture with them. The shared areas provide a choice of communal space with opportunities for people to meet their relatives and friends, and if more privacy is required then people can go to their own rooms. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 16 There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets located around the home. The home was well lit, clean and tidy and fresh smelling. Since the last inspection, all the lounges and the entrance hall and stairs have been redecorated and new carpets fitted. This work has been carried out to a high standard. A sensory garden has also been built at the entrance to the home and was reported to be well used in the warmer weather. This area is easily accessible for service users. It was reported that the conservatory area and the dining room are to be recarpeted in the New Year. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 17 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. People are supported by a sufficient number of staff. The home’s recruitment systems were found to be satisfactory, and protect the best interests of people living at the home. Staff receive satisfactory training. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty rota showed that there is a satisfactory mix of qualified and unqualified staff working at the home, appropriate to the assessed needs of the service users, the size, layout and purpose of the home. The home’s manager said that she keeps the staffing levels under constant review, and that in the near future the levels are being increased. The rotas confirmed this. Domestic and catering staff are employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met, and the home is maintained in a clean and hygienic state. The records show that two written references are obtained before appointing a member of staff, and any gaps in employment records are explored. New staff are confirmed in post only following completion of a satisfactory CRB (Criminal Records Bureau) check and satisfactory check of the Protection of Vulnerable Adults and NMC (Nursing and Midwifery Council) registers (where appropriate). Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 18 The training records show that the staff training and development programme makes sure that the staff meet the changing needs of service users. Staff were very clear about their roles and responsibilities and understood the management and reporting structures for the home. Training records showed staff were up to date with all areas of mandatory training, and there was evidence of specific training linked to older people e.g. dementia care, palliative care. 43 of the care staff are at least NVQ II qualified, with 2 others working towards the award and s further 8 ready to be enrolled on the award. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 19 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, 33, 35, 38. The manager is fit to be in charge and is of good character. She is able to discharge her responsibilities fully. There are good systems in place that are to be used to monitor the quality of the care provided by the manager and staff. The health and welfare of people living and working at the home is promoted. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the required qualifications and experience to run the home. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 20 It is clear from discussions with the manager that she is a very caring person and is focused on the needs of people living at the home. The manager and staff make sure that so far as is reasonably practicable, the health, safety and welfare of service users and staff is promoted. This is done by way of staff training, fire safety system testing, risk assessment and safety system monitoring. Staff explained that they take part in fire drills, and have received fire safety training, along with health and safety training. The records supported this. The staff said that they receive formal supervision, and the records confirmed this. The home has a detailed quality assurance scheme. This involves obtaining feedback from service users, their families and professionals. Once feedback is received, than a report on the quality of care is published. This was seen at the time of this visit. Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X X X X X X 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 X 3 X 3 X X 3 Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Cleveland House Nursing Home DS0000001112.V314061.R01.S.doc Version 5.2 Page 24 - 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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