Inspection on 31/07/07 for Cleveland Park Care Home

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cleveland Park Care Home 20/08/09

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 15/08/06

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

CARE HOMES FOR OLDER PEOPLE Cleveland Park Care Home Cleveland Road North Shields Tyne And Wear NE29 0NW Lead Inspector Ian Armstrong Key Unannounced Inspection 31st July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cleveland Park Care Home DS0000065838.V343936.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 Position Vacant Care Home 62 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (61) of places Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admission into the home of residents to receive personal care should only occur where assessment confirms the persons care needs and lifestyle are compatible with those of the existing residents. 22nd January 2007. Date of last inspection Brief Description of the Service: Cleveland Park is a care home with nursing. Providing care for older people with enduring mental health problems. Care in the home is provided by Registered Mental Nurses supported by care staff. The home is situated in North Shields in Cleveland Park Road close to local shops and good public transport links. The building is comprised of two floors with resident bedrooms on each floor all with en-suite facilities. Each floor has lounge and dining rooms with a number of bathrooms, toilets and shower facilities. The home has its own kitchen and laundry services. The philosophy of care is to support the residents in their activities of daily living and to provide for their physical, mental, and social care needs. On the day of the inspection there were sixty residents in occupation twelve males and forty-eight females. Fees in the home range from £365 to £533. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • • • • • Information we have received since the last visit on 22nd January 2007. How the service dealt with any complaints & 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 & other professionals. The Visit: An unannounced visit was made on 31st July 2007. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: What has improved since the last inspection? Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 6 Decoration to some bedrooms, dining rooms and corridor areas. A better range of activities is occurring for the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good assessments are carried out before and after admission to ensure that peoples needs can be planned and properly met. Detailed information is available to help people make informed choices about the service before moving in. The home does not provide intermediate care. EVIDENCE: Four residents pre-admission assessment documents were read all of these were comprehensively completed to a good standard. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 9 Copies of the homes service user guide, statement of purpose and complaints policy are given to all new clients and their relatives the standard of the documentation is good. A relative spoken to said she had been given good information about the homes services and had had the opportunity to visit prior to the admission. She said if she had any concerns she would approach the manager or staff and was confident these would be addressed appropriately. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care planning is good with the exception of social care plans these are too generalised and do not address individual needs. Healthcare needs are generally well met and adopt a multi-agency approach. This helps residents to stay healthy. Robust medication systems are in place to make sure that residents are not put at risk. EVIDENCE: In all four residents records there were a good range of assessments written these were for physical health needs, continence, nutritional, pressure care, mental health, and social care. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 11 All assessments were being regularly evaluated and updated. Care plans were well written and being evaluated each month with the exception of social care plans these are too generalised and do not address individual needs. Information from social care assessments needs to be utilised to develop better social care plans. Reviews of care needs were structured very six months with relatives in attendance relatives had signed review forms to say these had been discussed and agreed. Evidence was recorded in all four files of visits from other healthcare professionals these records were comprehensive. Residents preference for gender of staff for personal care tasks was recorded. Records showed that residents wishes about what clothes to wear was being identified and met. Spoke to two members of staff involved in writing care plans for these residents who were knowledgeable about meeting their care needs. Checked the systems for the administration, receipt, storage and disposal of medicines these were satisfactory, The stock balance of three residents controlled medicines was also checked and was found to be correct. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to retain their independence, and are fairly well supported to make choices, however more needs to be done to address individual social care needs. The residents have good opportunities to take part in a variety of leisure pursuits and interests, which help them maintain links with the local community. Mealtimes are flexible to suit individual preferences and lifestyles. Residents are given choice and sensitively supported to eat meals where they have specific needs. EVIDENCE: Social care plans in those residents files read are too generalised. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 13 Information identified and recorded in residents social care assessments about lifestyles and preferences is not being used in care plans to meet each residents individual social care needs. The homes weekly activities programme was seen this shows a good variety of activities occurring. The home writes a monthly newsletter, information about activities for residents is included in this. Events held on a regular basis are, Family support group weekly meetings, alternative Fridays wine and cheese parties, pat a dog weekly visits, each month a multi-denominational religious service is held in the home by a local vicar. Records were seen of individual residents trips out to local shops also records of residents craft making, flower arranging and sandwich making. Events that have occurred in the recent past home cinema Gene Kelly Singing in the rain, Body shop party, Visiting entertainer singer. The lunchtime meal was observed food was pork casserole or quiche with mixed vegetables and potatoes, sweet was rice pudding or yoghurt or ice cream. Staff were in attendance and assisted residents who needed help to eat interactions between residents and staff was good. Soft food diets these could be made more attractive to eat by the use of food shape moulds. Menus were seen these showed a good variety and choice of food being offered. Relatives spoken to said food and meals in the home were good. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place and clearly displayed to ensure that complaints are dealt with effectively and to the satisfaction of the complainant. Clear protection procedures are in place to protect residents from risk of harm. EVIDENCE: Policies and procedures for complaints and protection were read and are comprehensive. A copy of the complaints procedure is kept in the entrance area of the home. A number of homes staff were spoken to and had good knowledge of procedures to follow. Staff training records showed all but two staff members had been trained in Protection of vulnerable adults further training for the two staff is being organised. Relatives spoken to said they had been given copies of the complaints procedures and were happy the home would address any concerns they might have. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is generally clean and is being reasonably well maintained. EVIDENCE: Visited a number of resident bedrooms décor and furnishings seen were satisfactory there was evidence of lots of personal effects and possessions in these rooms. Some bedrooms were malodorous. En-suite facilities were clean and tidy however the extractor systems in all of those rooms visited were not working. Dining areas were seen upstairs and downstairs curtains need to be fitted to windows in both of these rooms. The upstairs dining room, chairs and tables here are looking worn and old. The blind to the downstairs corridor window was broken. Lounge areas were generally clean and tidy. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 16 The kitchen was visited the room was found to be untidy there was food debris to various parts of the floor. The staff toilet in the kitchen was broken and out of use, the staff toilet window needs a blind fitting. The corridor walls leading to the food store are in need of decoration. A refrigerator was seen dairy products were being stored below meats. The laundry was visited water damage to the ceiling has occurred from building work on the upper floor to provide 4 additional resident bedrooms the area where this work is being carried out is being adequately screened for the protection of the residents. Relatives spoken to said the home is generally clean and tidy when they visit. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are in post to meet the diverse needs of residents. Opportunities for training are good. This enables staff to learn new skills to better support residents in all aspects of their lives. Recruitment procedures are currently not being carried out correctly which help to prevent risk of harm to residents. EVIDENCE: Duty rosters showed the following levels of staffing being maintained am, 2 qualified and 9 care staff, pm, 2 qualified and 8 care staff, nights 2 qualified and 4 care staff. Rosters showed that staff on duty on the visit day were correct. Two staff recruitment files were read and all checks were in place with one exception in both files there was only one written reference. Staff supervision records were seen these are taking place two monthly and a good standard is being achieved. National Vocational Training in the home is good 20 staff have been trained to NVQ level 2 or above this being 75.2 of the workforce. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 18 Induction and staff training records were inspected and were satisfactory. Client centred training has been organised with the Alzheimer’s Disease Society and is soon to commence Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance systems are in place but are still being developed. This will help to shape the quality of the service and ensure that it is run in the best interests of the residents. Good systems and practises are in place that help to ensure residents and staff are safe from risk of harm. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 20 EVIDENCE: New clinical manager not on duty on day of inspection she is a registered mental nurse of 15 years experience and has a Diploma in Nursing. Reports of regulation 26 manager visits were seen and are satisfactory. Health and Safety meetings held two monthly minutes were checked agendas were appropriate and satisfactory. Staff and relative meeting minutes were also checked were appropriate and evidence of actions being taken on matters raised. The systems for the management of residents monies were checked, 3 residents transactions showed evidence of regular expenditures money balances were correct and there was two signatures for all transactions. The homes fire log book and accident book records were inspected and are satisfactory. Utility certificates were all checked and were satisfactory. Service user/relative surveys have not been sent out for over a year. Staff in the home were spoken to and were aware of the procedures to follow for infection control. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? 7 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 15.1 Requirement A social care plan must be written for all residents, these plans must address each individuals needs. Outstanding since 31/03/07. Residents individual hobbies and preferences must be met. The system of ventilation in resident en-suite facilities must be repaired. Outstanding since 28/02/07 The window blind to the downstairs corridor must be repaired. Curtains must be fitted to both dining room windows. The upstairs dining room furniture must be renewed. The laundry ceiling must be repaired on completion of the building work. The kitchen staff’s toilet must be repaired. A blind must be fitted to the toilet window. DS0000065838.V343936.R01.S.doc Timescale for action 31/10/07 2. OP12 16.2(n) 31/10/07 3. OP19 23.2(p) 31/10/07 4. 5. 6. 7. 8. OP19 23.2(b) 23.2(b) 23.2(g) 23.2(b) 23.2(b) 31/08/07 30/09/07 31/10/07 31/10/07 31/08/07 OP19 OP19 OP19 OP19 Cleveland Park Care Home Version 5.2 Page 23 9. 10. 11. OP38 16.2(g) 16.2© 19.1(a,b,c ) OP26 OP29 Dairy products must not be 01/08/07 stored in refrigerators below raw meats. Carpets in those bedrooms 06/08/07 identified as malodorous must be cleaned. All staff employed by the home 01/08/07 must have two written references. 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 OP15 Good Practice Recommendations Food shape moulds should be used to make soft diet foods more appealing and attractive to eat. Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cleveland Park Care Home DS0000065838.V343936.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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