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Inspection on 08/12/05 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 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Residents reported that staff meet their needs at the home. Although not inspected on this occasion, it was evident from observation and discussion with residents that they enjoy taking part in activities organised by the home. The home was clean, tidy and odour free. Following assessment, specialist equipment is provided to residents to promote independence.

What has improved since the last inspection?

Some requirements and recommendations from the previous inspection have been addressed. It is positive to note that care plans are now being reviewed on a monthly basis by staff.

What the care home could do better:

Improvements need to be made to some areas of record keeping at the home so that records are fully completed, accurate, specific and up-to-date so as to assist staff and to promote the safety and welfare of residents. An audit of the quality of care and nursing provided at the home must be undertaken and should include the views of all stakeholders so that the service provider can evidence that the home is being run in the best interests of thosewho use the service. Reports of regulation 26 visits must also be supplied to the commission as required. Staff, who have not yet done so, must receive up-to-date fire safety training.

CARE HOMES FOR OLDER PEOPLE Cleveland House Nursing Home 2 Cleveland Road Edgerton Huddersfield West Yorkshire HD1 4PN Lead Inspector Jacinta Lockwood Unannounced Inspection 8th December 2005 08:50 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.V271756.R01.S.doc Version 5.0 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.V271756.R01.S.doc Version 5.0 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) 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.V271756.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 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. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection of Cleveland House Nursing Home on 8 December 2005. The inspection lasted eight hours. The following inspection methods were used: examination of a sample of documents including residents’ care plans and assessments, medication, staffing rota and training records, the home’s quality assurance including regulation 26 reports, accident records, some policies and procedures. The inspectors also spoke with residents, staff and management and undertook a limited tour of the premises. The inspectors would like to thank residents, staff and management for their time and hospitality throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvements need to be made to some areas of record keeping at the home so that records are fully completed, accurate, specific and up-to-date so as to assist staff and to promote the safety and welfare of residents. An audit of the quality of care and nursing provided at the home must be undertaken and should include the views of all stakeholders so that the service provider can evidence that the home is being run in the best interests of those Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 6 who use the service. Reports of regulation 26 visits must also be supplied to the commission as required. Staff, who have not yet done so, must receive up-to-date fire safety training. 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. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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.V271756.R01.S.doc Version 5.0 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): EVIDENCE: None of these standards were assessed on this occasion. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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, 9 Generally, care planning is to a good standard, and reflects residents’ health, personal and social care needs. Poor practice with regard to the operation of the home’s medication system has the potential to place residents at risk. EVIDENCE: The care plans of four residents were inspected. These provided a good level of detail, including an assessment of risk and have been kept under review. However, a recommendation is made regarding clarity of the instructions for staff within the care plan. Entries such as “check regularly”; “ensure fluid intake adequate” are open to interpretation. Instructions to staff should be clear and specific. Also when referring to continence aids, the type of aid to be used should be clearly specified. Staff need to pay attention to detail as daily reports did not always reflect the outcome to be sought for the resident. And the numbering system used within the daily record did not always correspond with the numbering on the care plan. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 10 It is recommended that all documentation be fully completed, for example, property records. Documents should also be clearly signed and dated to ensure the currency of the information. Medication is stored securely. It was not possible to fully reconcile the stock of medication inspected. This was the fourth inspection where inspectors have found problems with the operation of the medication system. Poor practice in this area has the potential to place residents at risk. An immediate requirements notice was issued on the day of the inspection for action to be taken to improve practice in this area. Where a person has an allergy to a medicine this should be recorded on the medicines administration record sheet in the space provided and clearly highlighted on the residents’ care plan. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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): EVIDENCE: None of the above standards were assessed on this occasion. The registered manager reported that a previous recommendation regarding meal-time arrangements has been addressed. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: None of the above standards were assessed on this occasion. However, records show that all staff have now received adult protection training. Staff spoken with had a good general understanding of the action to take was abuse to be seen or suspected. Residents spoken with said that they felt safe living at the home. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 13 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): 22, 26 Residents have the specialist equipment they require. The environment at Cleveland House was clean, tidy and free from unpleasant odours, although a recommendation has been made regarding the positioning of the clinical waste bin. EVIDENCE: The registered manager explained that the home’s emergency call system operates satisfactorily, but that a review of the system has been included within the home’s budget for the next financial year. Those bedrooms seen provided residents with the equipment they require to maximise their independence. Residents expressed satisfaction with their personal accommodation. The previous requirement for a lidded bin for the disposal of clinical waste has been addressed. However, the positioning of the bin should be reviewed as it Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 14 was being stored next to a trolley of laundered linen. A recommendation has been made. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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, 28 The numbers and skill mix of staff meets residents’ needs. NVQ training is progressing to ensure that staff have the necessary skills and knowledge to meet residents’ needs. EVIDENCE: Staffing levels and the skill mix of staff were sufficient to meet the needs of current residents. The manager explained that staffing levels were to be increased, in January 2006, to eight on the morning shift to take account of the increasing dependency needs of residents and with regard to issues of time around care planning and staff training. A new deputy manager is to start work at the home in January 2006 and care assistant vacancies were being recruited to. At present agency staff cover vacant shifts and, where possible, the same agency staff are used to provide consistency for residents. NVQ training is progressing at the care home to ensure that care staff have the necessary skills and knowledge when providing care to residents. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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): 31, 33, 35, 37, 38 The manager is registered with the commission and is fit to be in charge of the care home. There was no written information available in the form of a quality audit report to evidence that the home is run in the best interests of its residents. The home does not manage residents’ personal monies. Record keeping at the home is generally satisfactory. Processes are in place to ensure that the health, safety and welfare of service users and staff are promoted and protected. Up-to-date mandatory training for staff will enhance this. EVIDENCE: The inspectors were shown an analysis regarding the manager’s performance following completion of a survey by staff, the findings of which were generally positive. Staff spoken with reported that the manager was approachable and available for support. The commission has registered the manager as being fit to be in charge of the care home. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 17 The policy and procedure regarding quality audits could not be located at the time of this inspection. The manager reported that an annual survey is sent to residents and their relatives but that quality reports were not available, as an insufficient number of surveys were returned over the last two years. Although residents’ views must be sought as part of the quality audit, so should the views of other stakeholders. The quality of care provided at the care home, including the quality of nursing must be reviewed on a regular basis with a copy of any report being supplied to the commission and made available to residents. The registered provider should refer to standard 33 of the National Minimum Standards for Older People to assist in completing the home’s quality review. Residents spoken with expressed satisfaction with the quality of care provided at the home. Monthly reports following regulation 26 visits are not being supplied to the commission on a consistent basis and this must be addressed. The manager explained that the home does not hold any personal monies for residents. It was said that residents’ families deal with any finances. Record keeping at the home was generally satisfactory, however, information on residents’ social and leisure activities should not be kept on the file of other residents. An alternative method of recording such information on individual files should be introduced. The manager’s name and shifts to be worked are not included on the home’s staffing rota as required. A requirement is made for all staff working at the care home to be included on the staffing rota. Accident records are well documented and maintained. A flowchart indicating who should be informed when an adverse incident occurs does not include the Commission for Social Care Inspection. The commission should be included so as to assist staff in notifying all relevant bodies. Not all staff have received up-to-date training in fire safety and this must be addressed. Following the previous inspection, a recommendation was made for security arrangements to be reviewed at the home when doors are left open during warm weather. The manager explained that a balance had to be sought between the potential risk to residents and promoting their independence. However, security arrangements should be kept under review. Residents spoken with said that they felt safe at the home. Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X X 1 1 Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement Accurate records of all medication held at the home must be kept. (Timescale of 30.09.05 not met). The registered person must undertake a quality audit of the care and nursing provided at the home. A copy of any report must be supplied to the Commission and made available to residents. The name and shifts to be worked for all staff employed at the home must be included on the staffing rota. Unannounced visits must be carried out in accordance with regulation 26 and a copy of any report supplied to the Commission. Those staff who have not yet received up-to-date fire safety training must do so. Timescale for action 16/12/05 2 OP33 24 31/03/06 3 OP37 17(2) Schedule 4 (7) 26 08/01/06 4 OP37 31/01/06 5 OP38 18(1)(c)(i ) 31/03/06 Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 20 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 2 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Daily records should: • Reflect the outcome to be sought for the resident; • Clearly relate to the care plan. All care planning and related documentation should be fully completed and be clearly signed and dated. Where a person has an allergy to a medicine this should be recorded on the medicines administration record sheet in the space provided and clearly highlighted on the residents’ care plan. The clinical waste bin should be repositioned. The registered provider should refer to standard 33 to assist in completion of any quality review of the services provided by the care home. Information on residents’ social and leisure activities should not be kept on the file of other residents. An alternative method of recording such information on individual files should be introduced. All staff should receive 2 fire lectures and 2 fire drills in a 12 month period. 4 5 6 OP26 OP33 OP37 7 OP38 Cleveland House Nursing Home DS0000001112.V271756.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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