Inspection on 20/08/09 for Cleveland Park Care Home

This inspection was carried out on 20th August 2009.

CQC 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 CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cleveland Park Care Home 23/06/09

Cleveland Park Care Home 11/03/09

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Cleveland Park Care Home Cleveland Road North Shields Tyne And Wear NE29 0NW Lead Inspector Anne Brown Key Unannounced Inspection 20th August 2009 09:00 DS0000065838.V377217.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.V377217.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.V377217.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.V377217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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 following categories: 2. Dementia - Code DE, maximum number of places 66 The maximum number of service users who can be accommodated is: 66 23rd June 2009 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.V377217.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 one star – adequate service. This means that the people who may use this service experience adequate quality outcomes. We have 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 services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out:Before the visit:We looked at:• • • Information we have received since the last inspection on 23rd June 2009. Any changes to how the home is run. The provider’s view of how well they will care for people. The visit:• An unannounced visit was made on 20th August 2009 During the visit we: • • • • • • Talked to the project manager, area manager and staff on duty. Looked at assessment information about the people who may use the service and how well their needs are met. Looked at some policies and procedures. Looked at staff training programmes. Looked at the home’s recruitment and selection procedures. Looked around the premises to make sure they were clean, safe and comfortable. We told the project manager of the home what we found. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 6 What the service does well: Thorough assessments are carried out prior to people being admitted to the home. This helps ensure their needs can be fully met. People are provided with good information about the home which helps them decide whether it is a suitable place for them to live. Training is being provided to the staff to help ensure they have the correct skills to meet individual needs. The home has a robust recruitment and selection process to help protect people from abuse and to help ensure appropriate staff are appointed to meet the needs of the people living in the home. The project manager is committed to making improvements and ensuring good standards are met. What has improved since the last inspection? The project manager has implemented lots of systems to help ensure standards are improved and maintained. Work is taking place to improve the premises. There is a maintenance programme in place and paintwork throughout the home is being renewed before other changes are made to make the environment more stimulating for people with a memory loss. New cleaning routines have been introduced so all areas receive a deep clean on a regular basis. A new system has been put in place to ensure food supplies are properly stored, dated when opened and discarded when the use by date is reached. A training programme and matrix is in place to ensure staff receive appropriate training to meet the needs of the people living in the home. All staff now have a formal supervision session every month. They have been reminded of their responsibilities with regard to respecting privacy and dignity, Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 7 infection control and the procedure for reporting accidents, incidents, concerns and complaints correctly. Relatives Meetings are now being held every month as the project manager is keen to gain their views and involve people in how the home is run. He also holds surgeries so people can call in and discuss any concerns or ideas they may have. Raised flower beds are planned for the enclosed court yard and the project manager has applied to rent an allotment where people can grow vegetables and flowers. The home is advertising for an activities organiser who can work with the care staff to introduce suitable activities and social stimulation for people to participate in. The management are currently in the process of reviewing and auditing all care plans to help ensure people’s needs are fully met. What they could do better: The management must continue to audit and review all care plans to ensure staff have access to up to date information and guidelines so they can meet the needs of the people living in the home. Staff must ensure personal care charts are fully completed to show people have received personal care when they need it. More activities should be introduced which are appropriate for the people living in the home. Improvements to the environment should continue to ensure it is more suitable for people with memory loss. The mechanical ventilation devices must be repaired in toilets and en suite facilities. The carpet edging in one bedroom must be made safe to ensure it does not post as trip hazard. Appropriate storage facilities must be provided in all en suite facilities. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 8 Toothbrushes must be appropriate stored to make sure they are hygienic. 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.V377217.R01.S.doc Version 5.2 Page 9 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.V377217.R01.S.doc Version 5.2 Page 10 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): 3 and 6 People using 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: The home obtains a copy of the local authority or hospital discharge assessment before people are admitted to the home. This helps them decide if they can offer the care and support needed for each person. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 11 The organisation has its own pre-admission assessment documentation that is routinely used to assess a person’s level of need. To help identify each person’s needs, wishes and beliefs, the home uses a range of professionally recognised assessment tools. These include skin care, mobility, nutritional needs and areas of risk. No admissions have taken place since the last inspection. The home does not provide intermediate care. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10 People using 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’s health and personal care needs are generally well met but care planning is not sufficiently detailed to ensure this happens in a consistent way. EVIDENCE: The manager is currently in the process of auditing and reviewing the care plans for each person living in the home. Care staff have received care planning training to help them to produce plans that fully address individual needs. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 13 Six care plans were examined. The majority had been evaluated and reviewed. For one person a behaviour plan had not been put in place following a recent incident. Neither did staff have access to guidance regarding possible disinhibited behaviour/sexuality issues. Another did not mention an incident where someone could be put in a vulnerable position. The care plan on death and dying did not reflect the family’s wishes re resuscitation and aggressive interventions. There was no guidance for staff about what they can and cannot do regarding these wishes and no mental capacity assessment had been carried out for the person involved. Food and fluid charts had been completed when necessary. The manager had introduced personal care charts which the staff are requested to sign when they carry out personal care on a daily basis. Gaps were found in each record that was examined. This does not provide evidence that the tasks had been carried out satisfactory and show that people are given the opportunity to have a bath and shower on a regular basis. Staff who were spoken to said they felt the charts were helpful but need to be fully completed on a daily basis. The care records showed that people living in the home have access to external health care services. GPs are regularly consulted for advice and treatment. People are supported to use dental, chiropody and optical services in the community. Good relationships were observed between people who live in the home and the staff on duty. Staff were aware of the peoples’ individual needs and were seen treating people with respect. People are able to access their own bedrooms at any time and can choose how to spend their time. All staff were observed to be respecting peoples’ privacy and dignity. The pharmacist inspector carried out a random inspection on the medication system in the home. His report stated that the system was in accordance with the pharmacy guidelines. The manager confirmed that the three recommendations made had been implemented. Cleveland Park Care Home DS0000065838.V377217.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): 12, 13, 14 and 15. People using 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. A limited range of activities and events are provided in the home for people to enjoy and they are able to make personal choices. Friends and family are encouraged to visit and participate in any events taking place. EVIDENCE: No activities were taking place at the time of the inspection. The manager confirmed that activities usually take place late in the afternoon. These include bingo, speaking stories, newspapers, dominoes, music groups and walks to the local shops. The manager had recently brought his dogs to visit the home and said people really enjoyed this. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 15 The home has advertised to appoint an activities organiser. Activities are being discussed with staff during their supervision sessions to ensure they are aware that engaging people in activities is part of their role on a daily basis. The services of a specialised domiciliary care agency have been bought in for one person living in the home so that he can access more facilities in the local community. The organisation are introducing “Making Living Better”. This is a package which helps people with memory loss to make decisions and choices. The managers have received training and all staff were due to receive this training, commencing the week following the inspection. The manager and activity organiser (when they are in post) are to receive training with a Clinical Psychologist regarding suitable activities for people with memory loss. New 1950s CDs have been purchased and one member of staff said people were really enjoying these. The manager has ordered activity tabards which include zips and pockets to assist people with memory loss. Raised flower beds have been ordered which are suitable for people in wheelchairs as well as those who are more physically fit. The manager has also applied to rent an allotment where people can grow vegetables and flowers. Part of the garden is to be turned into a vegetable patch and a shed is to be provided with seating Visitors are made welcome in the home and people are encouraged to keep in touch with their family and friends. One person is supported to visit his wife every two weeks which he said he really appreciates. There are facilities in each of the lounge/dining areas where visitors can make a drink. A temporary chef has been employed in the home. Four weekly menus are in place and a choice is available at every mealtime. At the time of the inspection people were offered a choice of liver and onions or fish fingers, peas, mashed potatoes followed by fruit and cream. Special diets are catered for. New plates have been purchased. These are coloured to help people with eyesight problems to identify what is on their plate at mealtimes. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 16 A new system has been put in place to ensure food supplies are kept in order and any out of date food is destroyed. The fresh meat and fish supplies are checked by the manager and the chef. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 17 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): 16 and 18 People using 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. There is a good system in place for dealing with complaints and staff receive training to help protect people from abuse. 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. Two complaints have been received since the last inspection. These had been satisfactorily dealt with. The manager holds surgeries each week when relatives can call into the home and discuss any concerns they may have. Recording complaints and reporting incidents have been discussed with all staff during their supervision sessions. This helps to ensure matters are recorded and appropriate action taken. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 18 Staff are required 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. Staff complete a twelve week course on safeguarding vulnerable adults as part of their National Vocational Qualification (NVQ) and a programme is in place for them to complete a course run by North Tyneside Council. This helps to ensure people are kept safe. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 19 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): 19, 20, 21, 24, 25 and 26. People using 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. Most parts of the premises provide people with a pleasant place to live but other parts are in need of repair and updating. EVIDENCE: Since the last inspection a lot of work had been completed to ensure the premises are clean and hygienic. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 20 All areas were much cleaner and more hygienic. The domestic on duty said all bedrooms are now deep cleaned on a regular basis as well as when necessary. Five shower rooms have been provided with new flooring, wall tiles and shower heads. These have been ordered for the remaining shower rooms. Taps in bathrooms and toilets have been repaired and baths and hand basins have been provided with plugs. The manager also has a ‘stock’ of plugs in case any go missing. Clinical waste bins have been provided. New handrails have been provided in toilets where the previous ones were rusty. A supply of hoists and slings have been purchased to assist with moving and handling. The doors and corridors on the first floor have been painted and a programme is in place for this to continue throughout the premises. The water pumps have been replaced so there is now a consistent supply of hot water throughout the premises. The kitchen has been thoroughly cleaned and new flooring provided. Seven day cleaning routines are now in place. The kitchen toilet has been thoroughly cleaned. A supply of new bed linen and towels have been provided. Soap dispensers have been provided and the home are awaiting delivery of paper towel dispensers. Three new bedrooms carpets have been ordered and the home is awaiting delivery of two new drugs trolleys. The manager has interviewed a handyman and an additional domestic assistant. He is awaiting criminal record bureau checks before they can be employed in the home. A part-time gardener post has been advertised. This will help to ensure the premises are kept in good order. It was noted that the following issues need to be addressed to ensure the premises are safe and comfortable. Mechanical ventilation devices were not working in some toilets and en suite facilities. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 21 The carpet edging in one bedroom was frayed and could pose a trip hazard. Some ceiling tiles were damaged or missing. The fridge in the ground floor dining room had not been defrosted when necessary. Some en suite are not provided with sufficient storage for toiletries etc. Toothbrushes were not stored appropriately to ensure they are hygienic. The home had recently been inspected by the Infection Prevention and Control team. The manager was awaiting dates when they can provide the staff team with infection control training. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29 and 30. People using 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 protected by the homes recruitment and selection policy and procedures. There are sufficient staff employed in the home who are trained to meet the needs of the people who live there. EVIDENCE: The files for the two most recently appointed members of staff were examined. There was evidence on the staff files to show that Criminal Record Bureau checks and two written references are received prior to staff being employed. The staff files were well organised so that information is easily accessible. There is a training and development plan and training matrix in place to help ensure staff receive mandatory health and safety training. Specialist training is also provided to meet individual needs. This includes incontinence, stroke and dementia. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 23 The manager is awaiting dates from the infection control team to confirm when they can provide training for the staff. The manager confirmed only four care staff have not achieved a National Vocational Qualification (NVQ) Level 2. These four people are now enrolled to complete this training. There is a moving and handling facilitator working in the home and another member of staff is to enrol to complete this training. Two members of staff on duty confirmed that the training provided is very good and met their needs. Formal supervision sessions had taken place and the notes were recorded. These sessions have been increased to one per month. Subjects that have been discussed include infection control, privacy and dignity and the procedure for reporting complaints and incidents. The shifts worked by the care staff are to be changed next week. The manager feels this will be more beneficial to the routines in the home and will ensure a senior staff member is always on duty. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 24 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): 31, 33, 35 and 38. People using 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 home is well run and is now managed for the benefit of the people living there and promotes their health and safety. EVIDENCE: The project manager is experienced in managing care homes for older people. He will be working in the home until a new manager becomes established. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 25 Since he has been employed in the home he has worked hard to make improvements in all areas. He is enthusiastic about making sure the home is run in the best interests of the people who live there and that standards are improved in all areas. He has plans about how to improve the environment so it is suitable, safe and more stimulating for people who have memory loss. This involves introducing themes to the corridors, e.g. seaside, shops, library etc. Relatives Meetings are now being held once a month so their opinions can be taken into consideration. The manager is also holding surgeries so relatives can call in and talk to him about any concerns they may have. A programme is in place to ensure all staff receive up to date moving and handling training. The moving and handling facilitator is carrying out an audit and risk assessments are being updated. Health and safety checks are being carried out monthly. The records showed that fire drills are carried out and fire equipment is checked on a regular basis. The staff have been reminded that all accidents must be well recorded and these are analysed on a monthly basis and appropriate action is taken if necessary. Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 26 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 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 2 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 X X X 3 Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement The management must continue to audit and review all care plans and guidance on risk taking/management. This will help ensure staff have good information to meet the needs of the people living in the home and keep them safe. Personal care charts must be fully completed. This will ensure people are given care that is appropriate to their needs. The management must continue to improve the environment to meet the needs of the people who live there. The carpet edging in one bedroom doorway must be made safe. This will help ensure the safety of the person occupying the bedroom. Appropriate facilities must be provided to store people’s toothbrushes. This will help ensure people’s health and well DS0000065838.V377217.R01.S.doc Timescale for action 31/10/09 2. OP8 13 31/10/09 3. OP19 13 31/12/09 4. OP24 13 30/09/09 5. OP26 13 30/09/09 Cleveland Park Care Home Version 5.2 Page 28 6. OP26 13 6. OP30 18 being. Mechanical ventilation units throughout the home must be in working order. This will promote odour control in the home. Previous timescale of 23/08/09 not met. On-going training that promotes privacy, dignity and communication with people who have dementia must continue to be provided. This will mean that staff have the skills and knowledge to understand people’s needs and provide the care they require. 31/10/09 31/12/09 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. 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. The provision of storage facilities in the en-suite bathrooms should be reviewed throughout the home for the benefit of residents. 2. OP17 3. OP19 Cleveland Park Care Home DS0000065838.V377217.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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. 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