Inspection on 04/12/08 for Cleveland Park Care Home

This inspection was carried out on 4th December 2008.

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 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 20/08/09

Cleveland Park Care Home 23/06/09

Cleveland Park Care Home 11/03/09

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 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Cleveland Park Care Home Cleveland Road North Shields Tyne And Wear NE29 0NW Lead Inspector Elaine Charlton Key Unannounced Inspection 4th December 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleveland Park Care Home DS0000065838.V373560.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.V373560.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 (5), Dementia - over 65 years of age registration, with number (61) of places Cleveland Park Care Home DS0000065838.V373560.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. 2nd June 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.V373560.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 1 star, this means that the people who use this service experience adequate quality outcomes. An unannounced visit was made on the 4 December 2008, to follow up requirements made at the last key inspection on the 2 June 2008. A total of five hours were spent in the home. A registered manager from another Southern Cross home in the area, who is covering for a period of sick leave, was present throughout the inspection. Before the visit we looked at: Information we have received since the last visit on 2 June 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. During the visit we: Talked with people who use the service, staff, and the manager; Arranged for an inspection of medicines and the medication administration systems to be carried out by a CSCI Pharmacist; 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 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.V373560.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Good progress has been made towards meeting the requirements and recommendations made at the last inspection. Eighty per cent of care plans have been updated in a person centred way giving staff better access to the information to look after people who live in the home. The quite room on the first floor is now in full use, meaning that people can use this to meet with family or to be on their own. The seating arrangements have been changed in the lounges to make them more comfortable and intimate for people using them. A programme of re-decoration has started as is carrying on throughout the home, making areas brighter and more comfortable for everyone. New furnishings have been ordered to make the lounge areas more comfortable for residents and their visitors. The manager bought and been given some memorabilia that is going to be used to ‘theme’ corridors as reminders of days gone by, and local areas, for the interest and enjoyment of residents. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 7 Activities and events for the pre-Christmas, Christmas and New Year periods are advertised and people are being encouraged to join in. Organisational strategy meetings are now concluded and the organisation agreed that it would be beneficial, as a large provider of care, to have regular, quarterly meetings with North Tyneside Council to promote issues of consistency and good practice. 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.V373560.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.V373560.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. 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. People are given good information to help them decide about moving into the home. Their very varied needs and wishes are fully assessed so that everyone is sure they can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home makes sure that it gets a copy of the relevant healthcare professional’s assessment of each person that moves into the home. These are kept in the resident’s personal file so that they are always available. Southern Cross, the organisation that owns the home, also has its own preadmission assessment document that is used to assess a person’s level of dependency. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 10 We looked at the admission documents for the only person admitted to the home since September 2008. All assessment documents seen were fully complete, dated and signed. The home does not provide intermediate care. Cleveland Park Care Home DS0000065838.V373560.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. Care planning is now more person centred helping to make sure that people get the care and support they need. The storage, administration and recording of medication within the home could be improved to protect against product deterioration and to show that people receive their medication as prescribed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the records for three people living in the home, one of which was for the person who had most recently been admitted to the home. These were provided by the Clinical Nurse Lead who also told us about the work staff had been doing to provide more person centred care plans that properly reflected peoples’ needs and wishes. The manager had just received the organisation’s ‘Reach for the Stars’ document. Managers are required to complete this over a six week period. It includes an assessment of person centred planning and nursing Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 12 competency/practice and is based on the inspection process and meeting National Minimum Standards. Each of the records we saw included some nice, personal information about the needs and wishes of the person concerned. This included comments about how people liked their food, why and for what they needed their glasses and about how staff should communicate with residents. Examples taken from the records were: ‘Likes meal on a small plate or she will not eat’. ‘Must wear her glasses, this will enhance communication and reduce risks’. ‘Staff need to speak in a way that means she can answer with yes or no’. We saw evidence of the correct documentation and body maps being completed where a person had been identified with an injury or skin deterioration. Wound assessments included details of the issue and what treatment/dressings were being given and/or had been applied. For one person though the dependency assessment had not been updated between June and October 2008. Other assessments we saw had been regularly reviewed but some evaluations of care plans were still limited and not outcome based. One of the records we saw showed that the resident had been provided with a wheelchair and profile bed to make their life more comfortable. They had also seen a range of healthcare professionals including their GP, chiropodist, district nurse, and social worker. For another lady staff had been given advice that included ‘staff must give reassurance to gain trust and co-operation’, ‘all procedures and interventions must be explained to gain co-operation’, and ‘likes to sleep with dimmed wall lights’. Two members of the nursing team have attended catheterisation training to up date their practice improving the quality of care people receive. We saw copies of the medicines policy located in both treatment rooms along with Royal College of Nursing (RCN) guidance (2002) and Royal Pharmaceutical Society of Great Britain guidance (2003). These are both old versions of the documents. The nurse undertaking the morning medication administration on the first floor had a well-prepared trolley with plenty of drinks, clean medicine pots, oral syringes and spoons. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 13 The approach to medication administration was good using a ‘no touch’ technique and giving plenty of encouragement to people. The nurse pointed out three pots inside trolley door containing medicines she had not yet administered. Two pots were labelled with a persons name but one was unlabelled. We were told that these were for people who had had an early breakfast and had left the dining room. The dangers of this practice were discussed with the nurse and the clinical lead nurse on duty. Downstairs the morning medication was administered as residents appeared for their breakfast. Additional arrangements were in place for medicines to be given before food, for example insulin and antibiotics. The timing of medication can be adjusted to meet the personal wishes/habits of residents. We reviewed a selection of Medication Administration Records (MAR) charts on both floors. There was an up to date list of staff signatures in front of each MAR chart file. Dates pre printed on MAR sheets. On the first floor we saw two MAR charts loose in the file with no identification photographs otherwise records were generally well maintained. There were no significant gaps in records, but occasionally some quantities of medication received had not been filled in so it was not always possible to do stock reconciliation. Other recording issues were two handwritten entries that had not been countersigned, a handwritten entry for Haloperidol that had not been signed and no quantity received had been entered and there was no date of opening on a Viscotears container. On the ground floor all eye drops/eye ointments were labelled with date of opening. There were two printed medication entries with no quantities included, 28 Omeprazole tablets were entered as received, 24 were recorded as administered but only 3 were left, and Amoxycillin suspension for two residents was not being stored in the refrigerator. There are treatment rooms on both floors for storing of medication. They are identical in design and fittings. On the ground floor the trolley and cupboard were clean and tidy. The spacious outer room had adequate bench space, washing facilities and space for documentation on shelves and in a filing cabinet. The temperature of the inner room and refrigerator were regularly checked and recorded. However, the refrigerators were factory fitted with a max/min thermometer and instructions for use were posted on the front of the refrigerators but these were not being used to record the temperature range. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 14 Medication for return was secure in a clinical waste bin inside the locked inner room. Waste is collected by a registered waste contractor and duplicate sheets detailing medicines for disposal were seen in use. A review of entries made did not enable dates of any collection to be identified. Entries consisted of a continuous list of medication and quantities but no details of the date of removal or staff signature to confirm medicines had been removed for disposal. Entries appeared up to date but a recent waste collection had taken place and not been recorded in the book. The next cycle of medication had been delivered recently and was securely stored in the inner room. Prescriptions go to home first and are checked and photocopied. A written record is maintained of other medication ordered. On the first floor the room was not as tidy and the recent delivery of medication was not secure within the inner room. The room is also used for meetings and to do dressings. A controlled drugs cupboard is installed on both floors and is secure within the inner but only the upstairs cupboard is used. Cupboards appear to meet safe custody regulations, are standard in design and securely fitted. A Medipost controlled drugs register is in use and all entries were complete with witness signatures and dates. They were accurate and legible. No discrepancies were noted. Two nurses carry out a daily controlled drugs check, which is recorded on a separate signed record sheet. A Doop kit was available for use. Medication audits are undertaken monthly by senior staff. We reviewed the audit for September 2008. Some boxes were ticked as satisfactory but did not always reflect current good practice. For example the audit states ‘recording max/min temperature of refrigerator as policy’ but this was not actually being done. The atmosphere within the home was observed to be much more relaxed than on our previous visit and we saw some nice interventions between staff and residents. Care workers were seen taking time to walk with people at their own pace, talking to them quietly as they went. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. People are helped to live a comfortable life and there are more chances for them to take part in individualised activities and events. Menus are assessed to make sure they are balanced and offer good levels of nutrition. Individual choices are only restricted by a person’s ability and/or their level of frailty. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People were seen having breakfast late into the morning. The choice of menu did not appear to be affected by the time a person got up. We saw toast, scrambled eggs and cereal being served. A Christmas Fayre and Christmas Party with entertainment have been organised and staff had started putting Christmas decorations up. There are two notice boards in the entrance hall. One identifies staff that work in the home and the other is used to put up posters for planned events. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 16 The inner hall on the ground floor was being decorated, but the manager has provided a coffee machine in this area so that relatives can help themselves to a drink whilst they are visiting and sitting in this area. The manager also told us about memorabilia he was collecting, and purchasing, to theme corridor areas and to make the environment more stimulating for the residents. Staff had come up with some good ideas about things that might be familiar to the residents, for example, the fish quay, local streets and pubs. Part of the refurbishment of corridors will include felt tactile boards that residents can take items from or add to without them looking as though something is missing. The seating in the lounge areas has been re-organised to make them more homely. There are plans to change the separate dining rooms and lounges back into four lounge/diners that people will be able to move between at will. We were told that new, flat screen televisions were going to be provided before Christmas. When the room layouts are changed it is planned to have one television room and one music room on each floor. Newspapers, journals and magazines are now delivered to the home on a regular basis and are kept in Perspex holders so that people can see them, take them away and look at them. People were seen using the seating in a variety of areas, the main lounges, small quite lounge upstairs and the hall way. We sampled lunch which was liver, turnip, broccoli and mash. Everything was nicely cooked and tasty. After lunch we saw a carer on the ground floor engaging with people and asking if they would like to play cards or dominoes. One lady who said she wanted to go to bed because there was nothing happening quickly ‘came alive’ when offered a game of cards. Said she didn’t know how to play but wanted a go. The home is also looking to recruit a new activities co-ordinator to promote this area of care. Cleveland Park Care Home DS0000065838.V373560.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. 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. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. We have made this judgement using a range of evidence, including a visit to this service. 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 witness. We were told that all staff have completed Protection of Vulnerable Adults (POVA) training with an external training organisation and are now attending the North Tyneside Council course. Twelve members of the staff team had completed the North Tyneside safeguarding adults course the day before the inspection. Staff have recently been reminded about confidentiality. 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. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 18 Nurses working in the home have a current registration with the Nursing and Midwifery Council. We saw evidence that these were up to date and regularly renewed. Staff from the home and the wider organisation co-operated with CSCI and North Tyneside Council safeguarding adults’ team to resolve issues of concern outlined in the previous report. Organisational strategy meetings are now concluded and the organisation agreed that it would be beneficial, as a large provider of care, to have regular, quarterly meetings with North Tyneside Council to promote issues of consistency and good practice. Cleveland Park Care Home DS0000065838.V373560.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. 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. People live in a safe environment that provides them with private accommodation. The layout of the dining room and lounge areas are not ideal but have been re-organised to make them more homely until major changes can be made. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Relatives, residents and staff expressed concerns about the layout of the dining rooms and lounges at the last inspection. We were told that changes are planned to provide two lounge/dining rooms on each floor. In the short term the manager has had the seating in the lounges re-arranged to make the areas more homely. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 20 A programme of re-decoration is underway. Paintwork in the lounges and dining rooms has been refreshed, and wall paper was being replaced in the entrance hall. We were told that the decorator is on ‘full alert’. The manager told us that bathroom doors, toilet doors and handrails along the corridors were being painted red so that people can easily identify them. He is also putting new self-adhesive tactile boards up in the corridors. With the dining room changes the manager is also looking to encourage use of the kitchen areas to engage peoples’ skills. It is also hoped to be able to arrange for the garden to be accessed from both ground floor lounges. Some of the damaged ceiling tiles have been replaced. There are some that still need to be changed but the handyman had run out of tiles. The laundry ceiling has been repaired and the area has been decorated, it is now clean and bright. As at the previous inspection the laundry was seen to be well organised and tidy. Hygiene routines in the home have improved and an additional member of staff has been appointed to the domestic team. A requirement was made at the last inspection to repair the air exchange system operating in the home. We were told that to repair the system is not cost effective. Staff are concentrating on improving hygiene routines, effective odour control systems and the replacement of furnishings and floor coverings in affected areas. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. 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. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at five staff training files that were selected at random. These contained evidence of staff receiving mandatory training in first aid, fire safety, moving and transferring, food hygiene, as well as safeguarding adults. The manager is to transfer all the staff training information to a computerised matrix that will give easy access to up to date information. The matrix is colour coded and highlights when training is due within the next six months and if it becomes overdue. Staff are issued with a copy of the Staff Handbook ‘Care with Commitment’. This covers the company philosophy, terms and conditions of employment, health and safety, grievances, whistle blowing, policies and procedures. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 22 Seventy five per cent of staff working in the home have achieved a National Vocational Qualification (NVQ) at a minimum of level 2. This is well above the National Training Organisation required minimum of 50 . NVQ level 3 training covers race relations, Sex Discrimination Act, Mental Health Act, Human Rights Act and explores equal treatment, discrimination and barriers to communication. Nurses keep their own personal development portfolios up to date. This is a necessary part of their registration with the NMC. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. People benefit from living in a home that welcomes and encourages their involvement. Staff supervision and records are not always up to date. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) was given to CSCI at the previous inspection in June 2008, it had been properly and fully completed. The manager told us that he had just received the organisation’s ‘Reach for the Stars’ document and he would be completing this over a six week period. Part of the project involves sending out questionnaires to get feedback on what people think about the home. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 24 The applicant for the post of registered manager is currently on sick leave so the process of registration has not been completed. The organisation has comprehensive fire safety training and arrangements and ‘sledges’ are in place to enable non-mobile residents to be quickly evacuated in the event of an emergency. Arrangements also continue to be in place to use a local pub and two sister homes should an evacuation of the home become necessary. The arrangements for looking after residents monies have not changed since the last inspection. The system is computerised and the home’s administrator is very competent with her management of this system. Maintenance and servicing arrangements are in place and remain up to date. Staff supervision is not carried out and recorded regularly. The quality of notes we saw were also limited. The home has regularly sent regulation 37 notifications to CSCI to report events and incidents since the last inspection. Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 25 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 3 9 2 10 3 11 x 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 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 2 X 2 X 3 2 3 3 Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 26 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 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.) 2. OP7 15 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.V373560.R01.S.doc Timescale for action 03/03/09 30/03/09 Cleveland Park Care Home Version 5.2 Page 27 3. 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 Inspector on the day of the inspection. 30/03/09 4. 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 5. 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 6. 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. 31/12/08 Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 28 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 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. 2. OP17 3. OP19 Cleveland Park Care Home DS0000065838.V373560.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V373560.R01.S.doc Version 5.2 Page 30 - 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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