Inspection on 11/03/09 for Cleveland Park Care Home

This inspection was carried out on 11th March 2009.

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

Cleveland Park Care Home 20/08/09

Cleveland Park Care Home 23/06/09

Cleveland Park Care Home 04/12/08

Cleveland Park Care Home 02/06/08

Cleveland Park Care Home 31/07/07

Cleveland Park Care Home 15/08/06

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Cleveland Park Care Home Cleveland Road North Shields Tyne And Wear NE29 0NW Lead Inspector Elaine Charlton Unannounced Inspection 11th March 2009 09:30 DS0000065838.V374923.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleveland Park Care Home Address Cleveland Road North Shields Tyne And Wear NE29 0NW 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) 0191 2585500 0191 2584141 cleveland.park@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Manager post vacant Care Home 66 Category(ies) of Dementia (66) registration, with number of places Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the followingcategory of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the followin categories: 2. Dementia - Code DE, maximum number of places 66 The maximum number of service users who can be accommodated is: 66 4th December 2008 Date of last inspection Brief Description of the Service: Cleveland Park provides residential and nursing care for older people with an enduring mental health problem. The home is on Cleveland Park Road in North Shields, and is close to local shops and good public transport links. The building has 66 bedrooms, all with en-suite facilities. Bedrooms are located at ground and first floor levels and there is a passenger lift to help people who may have mobility problems access the first floor. There is a large lounge and dining room on each floor as well as additional bathrooms, toilets and shower facilities. The home has its own kitchen and laundry. Care in the home is provided by Registered Mental Nurses supported by care staff. Fees depend on the service provided and the type of bedroom occupied. They range from £373.99 to £426.00 a week. The home has a statement of purpose and service user guide that give information to help people decide if their, or their relatives’ needs can be met. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star, this means that the people who use this service experience good quality outcomes. An unannounced visit was made 11 March 2009. This is the third key inspection this service has received in the last 12 months. A total of five and a half hours were spent in the home. The temporary manager was present throughout the visit. Before the visit we looked at: Information we have received since the last visit on 4 December 2008; How the home has dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; The views of people who use the service, their relatives, staff and other professionals who visit the service. We have also reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. During the visit we: Talked with people who live in the home, staff, the manager and the operations manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; We told the manager what we found. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 6 What the service does well: Gets good information about people wanting to move into the home so that everyone can be sure their care and support needs can be met. Continues to encourage the involvement of families and friends in events that take place in the home, and helps residents to keep in touch with their families and friends. Provides an environment where people can have their own private accommodation and move around the home, and garden, safely without constant supervision. Has a stable staff team who know the residents well and who support them in a sensitive and dignified way. Makes sure that people who live in the home are able to see a range of healthcare professionals as and when their health and wellbeing requires this. What has improved since the last inspection? All the requirements and most of the recommendations made at the last inspection have been met and those that remain are almost met. Care plans are now written in a person centred way promoting the privacy, dignity, choice and preferences of residents. The programme of re-decoration is continuing. Carpets and floor coverings are due to be laid in the next two weeks and then the new furnishings can be put out. Staff are working to promote areas of interest in the home and are collecting memorabilia and items of interest to stimulate residents. A new greenhouse and garden shed have been purchased and will be put up in the secure garden for residents to enjoy. Care plans and dependency assessments are now regularly reviewed and evaluated to reflect residents’ current needs. New flat screen televisions have been purchased for two of the lounges for the enjoyment of the residents. A new mini-bus has been purchased to be shared between 10 homes so that people can get out and about and enjoy their local community. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Cleveland Park Care Home DS0000065838.V374923.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 Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given good information to help them decide about moving into the home. Their varied needs and wishes are fully assessed so that everyone is sure they can be met. EVIDENCE: We looked at the records for two people admitted to the home since the last inspection. These were for one person needing nursing care and one residential. For both people the home had a copy of the local authority or hospital discharge assessment that gave clear information about the care and support they needed. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 10 Southern Cross, the organisation that owns the home, also has its own preadmission assessment documentation that is used to assess a person’s level of need. For both people, this assessment had also been fully completed. To help identify each person’s needs, wishes and beliefs, the home uses a range of professionally recognised assessment tools. These had been used for both new residents and included skin care, mobility, nutritional needs and areas of risk. The home does not provide intermediate care. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs of people who live in the home are set out in care plans that are person centred, respect their differing needs and promote their wellbeing. They get the support they need to be independent with medication or to take their medication safely helping to keep them well. EVIDENCE: As well as the records for the two new residents we looked at those for three more people who had lived in the home for longer periods of time. All residents’ records are now kept in a standard way using Southern Cross forms. Each service user plan we saw included up to date, person centred care Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 12 plans, setting out the care and support they needed, and how this should be provided. Care plans tell staff how they should let the person know what they were going to do and how that person would communicate their feelings. For example, ‘this lady responds to touch and eye contact’, ‘staff need to speak slowly and clearly’ and ‘only smiles or shouts’. We saw evidence of doctors being called when a resident had made a request, advice being taken from out of hours services and emergency services being called when necessary. There was some confusion in the records of one person about whether a care plan promoting pressure area care had been discontinued or whether there was another area of tissue damage needing attention. The manager dealt with this immediately. Staff should remove discontinued care plans to another area of the file so that this type of confusion does not occur. For the same person there was evidence in their assessment that they did not like to be rushed when care and support was being provided, but this was not reflect in their care plan. We were able to see that this had been a problem when the person lived in their own home and was supported by a home care service and had not been an issue for the home. Staff need to be clear about how issues have arisen, where and when, and what has been done. People living in the home can see a wide range of healthcare professionals to support their differing needs as and when they wish. There was very good evidence in one persons file about the support they had received when they started to have breathing problems, entries were dated, timed and clear. The nurse involved also made a good case for some additional equipment to be provided in the home and the operations manager agreed to organise this. There were also some very personal choices detailed in people’s care plans. One about a lady who liked to use moisturiser and makeup and another about a gentleman who liked particular toiletries but not aftershave. We were shown some guidance that had been put together to help staff understand what a care plan was for, what should be included and how this could help them to do their job. We were also told about additional training staff are to receive to help them with care plans. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 13 The care plans we saw had been regularly reviewed and evaluated. Evaluations have improved but some are still not particularly person centred. More detailed information was seen in the daily records. Where a need for equipment or specialist beds had been identified in a persons assessment we saw that the equipment had been provided. As well as providing the equipment, for one person, their care plan clearly detailed how often they had to be checked whilst in bed and the position the bed needed to be in so that they were comfortable and safe. Medication issues identified at the last inspection had been addressed. Staff were seen talking to and helping people to move around with sensitivity and patience. One member of staff apologised for not mopping a floor because she was spending time with a gentleman who needed a drink, this demonstrated that the person was clear about the importance of their role. People who live in the home were also seen making more use of the smaller, quieter areas. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are helped to live a comfortable life and the appointment of a new activities organiser will give them the chance to take part in more events and activities. Menus and meal choices offer people a good level of nutritious food that is tasty and home cooked. EVIDENCE: The manager told us that a new activities organiser had been appointed but they were still waiting for some checks to come back. The operations manager later said that these were complete and the person could be given a date to start work. There are plans in place to make sure that the new member of staff is able to work with and consult colleagues who already work in the same post and to see examples of activities and events taking place. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 15 A new mini-bus has been purchased that is to be shared by 10 homes. Cleveland Park had already had an outing to St Mary’s Lighthouse followed by an ice cream, and we were told that they expect to have an outing at least once a month. Staff at all levels are still coming up with ideas for introducing pictures, tactile boards and other items that will interest the residents into the home. Street name plates have been made for corridors and locks were being removed from the dining room/lounge areas to make it easier for people to move around. New flat screen televisions were seen in two lounges. We sampled both lunch options which were ham risotto or beef stew, with fresh vegetables and boiled potatoes. These were followed by home made rhubarb and custard. Each choice was tasty and nicely cooked, vegetables were fresh and plentiful. People were seen being given help and time to eat their meal. They can also choose not to have their meal in the dining room if they want. New carpets and floor coverings are being laid shortly after which the home will return to having four lounge/dining rooms, two on each floor, making the areas quieter and more intimate for the residents. In each of these areas there will still be some kitchen style units were visitors and/or family can make a drink. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The view of people who live in the home are listened to and they are protected from harm through policies, procedures and staff training. EVIDENCE: The organisation has policies and procedures in place supporting the acceptance, recording and investigation of complaints. There is a whistle blowing policy in place that encourages staff to report any incidents of poor practice they may see. Twelve staff completed North Tyneside Council safeguarding adults training in December. The operations manager is still trying to organise dates for the remainder of staff to do this training. Staff have to have a Criminal Records Bureau (CRB) check carried out at an enhanced level before they can work in the home. Care staff are also employed in line with the General Social Care Council (GSCC) code of conduct. Nurses working in the home have a current registration with the Nursing and Midwifery Council. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 17 The Commission for Social Care Inspection (CSCI) had received a letter raising concerns about the homes environment, meals and activities. All these areas have been addressed in the relevant sections of this report and where necessary requirements or recommendations made. The home continues to let CSCI know about events and incidents that affect the health and wellbeing of residents and properly records any accidents residents or staff may suffer. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe environment that provides them with private accommodation. Changes are taking place to make communal areas more homely, comfortable and pleasant for the residents. EVIDENCE: Following concerns expressed by relatives, residents and CSCI, arrangements are in hand to provide new floor coverings to the lounges and dining room areas, and to change them back into lounge/diners. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 19 This will mean that fewer people are using each room at any one time, and they will be able to decide to spend time in a room where they are comfortable or that is offering them the stimulation they are wanting. We saw the new furniture that has been bought for these areas. It is being stored in the home until the floor coverings and carpets are laid in mid-March. The serverys are also being removed from the dining rooms and lounges areas which will make them more spacious. Some units are being left so that visitors will be able to make themselves and/or their relative a drink. Re-decoration is still taking place in the home and areas are beginning to look much brighter and fresher. Advice has been sought about suitable colour schemes to be used to help and make life easier for people who have a dementia like illness. There are still some ceiling tiles in the corridors that are in need of replacement. An electrician was on site during the inspection removing key pads from the dining/lounge areas, and securing access to the kitchen. He also undertook to give some advice about closure devices for the double doors outside the lounge/dining rooms, and to replace a light fitting. One clinical waste bin was seen without a lid and there are still some swing bins in the home. These do not promote good infection control. The removal of the old floor coverings, carpets and furniture should also mean that any remaining odours in the home disappear. We talked to the manager and operations manager about a shower room that is being used for storage and the use of a sluice room for storing supplies. A garden shed and greenhouse have been purchased and will be put up in the garden area in the centre of the home. A quotation has also been obtained to improve and tidy up the garden areas outside the home. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are protected by recruitment and selection procedures that are properly followed. Staff are trained and continue to receive training to help them do their job. EVIDENCE: The organisation has policies and procedures in place for the recruitment and selection of staff. Evidence from the previous inspection was that these are regularly and properly followed. No new staff had been recruited to work in the home since the last inspection. Staff receive a copy of the organisations staff handbook called ‘Care with Commitment’, and we were told about new arrangements for the induction of people new to the service. This will include them being allocated a mentor to support them from day one of their induction programme. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 21 The handbook covers the company philosophy, terms and conditions of employment, health and safety, grievances, whistle blowing, policies and procedures. Seventy five per cent of staff working in the home has achieved a National Vocational Qualification (NVQ) at a minimum of level 2. This continues to be well above the National Training Organisation required minimum of 50 . Whilst working towards an NVQ at level 3, staff cover training in race relations, the Sex Discrimination Act, Mental Health Act, Human Rights Act and explores equal treatment, discrimination and barriers to communication. Nurses are responsible for their own personal development and portfolios. We were told that these are reviewed with each person as part of their annual appraisal. Regular personal development is a necessary part of a nurse’s registration with the NMC. Additional training is being arranged covering bowel management, infection control, and Parkinson’s disease. Plans are also in hand to role out further Yesterday, Today and Tomorrow training to promote staff understanding and the way they should work with people who have a dementia like illness. Cleveland Park Care Home DS0000065838.V374923.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a home that welcome and encourages their involvement and is run in their best interests, helping to keep them safe and well. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) was provided when we asked for it at an earlier inspection. It had been properly and fully completed. The home continues to be run by a temporary manager who is registered with CSCI for a sister home. The atmosphere in the home is welcoming and warm, Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 23 and the manager is happy to meet relatives or friends of residents at a time suitable to them if he is not around when they visit. The organisation has comprehensive policies and procedures that all staff have access to, as well as regular servicing and maintenance arrangements. The home’s certificate of registration and up to date insurance are displayed in the entrance hall. CSCI continues to receive notifications reporting any adverse incidents or events that may affect the health or wellbeing of a resident. The organisation has its own Dignity Champion and each home has been signed up to promote dignity in care. A local champion will be nominated for each home and will work closely with the organisation champion. Questionnaires are due to be sent out to residents, their families, staff and healthcare professionals, to get their views on how the home is being run and how well it is meeting peoples needs. Completed questionnaires will be returned to central office to be evaluated and a report prepared for the home. We looked at the fire and accident records. Both were seen to be up to date and fully completed. A properly trained member of the staff team is in the process of updating moving and handling plans and risk assessments. We saw evidence of this in three of the files we looked at. The operations manager carries out regulation 26 visits to the home on behalf of the provider. There have been no changes to the arrangements or computer systems that support the safe keeping of money on behalf of residents and acceptance of fees. The quality and accuracy of records in the home have improved considerably. A new schedule has been introduced to monitor staff supervision and appraisal arrangements. This came into effect on the 1 January 2009. We saw no practice during the inspection that would compromise the safety of residents or staff living and working in the home. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 24 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 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 2 X 3 Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans and guidance on risk management/taking must be expanded and written in a person centered way to ensure that residents needs can be fully met. This includes social care plans. This will mean that staff have the right information to provide individual care and support and that residents are able to take part in events and activities that interest them. (The previous timescale of 2 December 2008, is almost met. Eighty per cent of residents care plans had been updated when this unannounced inspection took place.) 2. OP9 13 Proper procedures for the safe handling of medication must be followed at all times. This will mean that people living in the home are kept safe and well. The general manager was given feedback about issues on concern by the Pharmacy Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 26 Timescale for action 30/03/09 30/03/09 Inspector on the day of the inspection. 3. OP19 23 Minor repairs and furniture replacements identified during the inspection and in this report must be carried out. This will mean that people live in a safe and comfortable environment. (Previous timescale of 30 September 2008, almost met.) 30/03/09 4. OP19 16 Hygiene routines within the home must be improved to promote good infection control. This will mean that people live in a clean and odour free environment. (Previous timescale of 31 July 2008, almost met.) 30/03/09 5. OP30 18 On-going training that promotes privacy, dignity and communication with people who have a dementia must continue to be provided. This will mean that staff have the skills and knowledge to understand residents’ needs and provide the care they need. Care plan evaluations and dependency assessments must be regularly reviewed and updated. This will mean that people living in the home are getting the right care and support and staff are kept up to date with changes in peoples well being. DS0000065838.V374923.R01.S.doc 31/12/09 6. OP7 15 30/03/09 Cleveland Park Care Home Version 5.2 Page 27 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 OP12 Good Practice Recommendations The opportunity for people to take part in more individualised social opportunities and activities should be expanded. 2. OP17 The organisation should continue to engage with the local authority to ensure that safeguarding training meets the needs of staff and promotes their understanding of local procedures. 3. OP19 The layout of the dining rooms and lounges should be reviewed to ensure that people have the opportunity to spend time in private and promote a quieter environment. Cleveland Park Care Home DS0000065838.V374923.R01.S.doc Version 5.2 Page 28 Care Quality Commission Yorkshire and Humberside St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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