Inspection on 21/07/06 for Cleveland View Care Home

This inspection was carried out on 21st July 2006.

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

The inspector 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 View Care Home 07/06/07

Cleveland View Care Home 25/01/06

Cleveland View Care Home 28/06/05

Cleveland View Care Home 02/02/05

Cleveland View Care Home 19/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Cleveland View Care Home Cleveland View Cargo Fleet Lane Middlesbrough TS3 8NN Lead Inspector Katherine Acheson Key Unannounced Inspection 21st July 2006 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 View Care Home DS0000059270.V301224.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 View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleveland View Care Home Address Cleveland View Cargo Fleet Lane Middlesbrough TS3 8NN 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) 01642 244977 01642 242077 Bondcare Homes Limited Mrs Joanne Britton Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who is under the age category is allowed to reside at the home. 25th January 2006 Date of last inspection Brief Description of the Service: Cleveland View is a purpose built care home that is registered to provide personal care to sixty older people. The home is split into two units. The ground floor of the home accommodates thirty older people and the first floor of the home accommodates thirty older people with dementia. Each unit has a large communal lounge area with an adjoining quiet lounge. The adjoining quiet lounge on the ground floor of the home is a designated smoking area for service users from both units. All bedrooms are for single occupancy and have en-suite facilities, with washbasin and toilet. All rooms are comfortably furnished and service users may personalise their rooms by bringing possessions and small items of furniture. Cleveland View Care Home is located close to a social club, churches and shops. Nearby there is a bus route into Middlesbrough town centre. On the date of this inspection the cost of care at Cleveland View was between £345 and £348 per week. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over two days, the 21st and 24th July 2006. A Regulation Manager accompanied and assisted the Inspector on both inspection days. The inspection in total lasted for eleven hours. Nine residents and two relatives were spoken to during the inspection, in addition five comment cards were received from relatives and one comment card was received from a resident. The Manager was not present for the inspection process, however the Area Manager of the home was and assisted with the process. Three care staff were interviewed and a discussion took place with Office Administrator and the Area manager of the home. Numerous records including care plans, menus, quality assurance and staff recruitment and training records were examined. A tour of the premises was carried out. A pharmacy inspection of the home was undertaken on the 13th June 2006, requirements 1 to 15 in the requirements section of this report were made as the result of this visit. A further inspection of standard 9, medication will be undertaken in the near future. What the service does well: What has improved since the last inspection? This was a first inspection visit to the home for the inspector and Regulation Manager. The Area Manager of the home is currently carrying out a full audit of the home highlighting areas of good practice and those areas requiring improvement. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 6 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. Cleveland View Care Home DS0000059270.V301224.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 View Care Home DS0000059270.V301224.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The quality in this outcome area is poor. Assessments of prospective residents are carried out to ensure that the home can meet their needs, however they are insufficiently detailed as are care plans. EVIDENCE: The Area Manager said that all prospective residents receive an assessment that is carried out by a social worker or other health care professional to ensure that the home can meet their needs. Staff at the home then carry out their own pre-admission assessment to ensure that the needs of the resident can be met at Cleveland View. Evidence was available on residents files examined during the inspection to confirm that this is the case, however assessments examined were not sufficiently detailed. On admission to the home, a plan of care is then developed for each resident. The home’s admission assessment of residents and care plans did not reflect the preadmission assessments that had been carried out by staff at the home The home does not provided intermediate care. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 The quality outcome in this area is poor, although residents are generally happy with the care provided, care plans and risk assessments are poor and not effectively evaluated leading to potential risks to resident’s health and welfare. EVIDENCE: Three plans of care were examined at random during this inspection. Care plans examined were not signed by the resident or their family member/representative to confirm that they had been involved in drawing up the plan of care or subsequent reviews. The home’s assessment of residents was not sufficiently detailed and care plans did not reflect the individual needs of the resident including care/intervention required to assist the resident. Care plans did not give a history of the resident or include likes and dislikes. One plan of care examined during the inspection highlighted that the resident had been referred to the dietician as the result of not eating and weight loss. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 10 The plan of care had not been updated in respect of treatment given/prescribed by the dietician. One plan of care examined highlighted a resident who was not particularly sleeping well, however it was not recorded in the plan of care intervention required to assist with the problem. One resident was highlighted as suffering from depression yet there was no plan of care in place in respect of this. Monthly reviews of plans of care were taking place, however, they were not sufficiently detailed. Evaluations were generalized and not comprehensive an example being for an update on a care plan for a resident who needed assistance when attending to their hygiene needs, “Care plan in place remains the same”. Care plans must be reviewed on a monthly basis and reflect the current situation, deterioration or improvements made by the resident. Staff at the home record on a daily basis the type of day a residents has had, daily recordings were not sufficiently detailed. Risk assessments require further development to ensure that they are individual/specific to the resident. Risk assessments must include specific preventative measures to help reduce/prevent the identified risk from occurring. Risk assessments must be updated on a regular basis to confirm effectiveness. Discussions with the management of the home prior and during the inspection highlighted that the Company were aware of the need to develop existing documentation. Nine residents were spoken to during the inspection, the majority of who spoke positively about life in the home. One resident said, “The staff are nice I can’t grumble. I get up and go to bed at different times, I never look at the clock I have worked hard all my life so I deserve a rest”, another said, “ I have been in the home just over a year. The staff are smashing always there when you want them”. One resident said, “This is a fantastic home”, another said, “On the whole the home is very good, however on occasions I have been left in my room for too long before care staff have returned to help me”. The same person went on to say, “One or two of the staff are lovely to me, I love them, one or two can ignore you, I have lost my voice through calling out”. One relative spoken to during the inspection said, “I am quite happy that my wife is being cared for”. Five comment cards were received from relatives and one from a service user in respect of the care/service that is provided by the home. Comment cards received did not highlight any concerns in respect of care provided, however comments were made regarding the environment, cleanliness, lack of activities and staffing which will be reported on in the relevant section of the report. Residents spoken to confirmed that their dignity and privacy was respected. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 11 A discussion/notification prior to the inspection of the home highlighted that the home do not have or provide pressure relieving mattresses for residents. If a resident develops a pressure sore or is highlighted as being at risk of pressure damage then a mattress is arranged and provided by the District Nursing Service. A discussion took place with the Area Manager during the inspection regarding the lack of pressure relieving equipment available within the home environment. She said that she is to discuss the issue with Senior Management of the home. An additional inspection of the home was undertaken on the 13th June 2006 in respect of medication systems. Areas highlighted as requiring further development are detailed in the requirements section of this report. A further inspection of standard 9, medication will take place in the near future. Cleveland View Care Home DS0000059270.V301224.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality outcome in this area is adequate. Visitors are made to feel welcome and residents in general enjoy the food that is provided. However activities provided by the home are limited and do not provide residents with stimulation. Although some residents are able to exercise choice others are not supported/enabled to go out independently. EVIDENCE: The home employs an Activity Co-ordinator to work twenty hours per week. The Area manager said that the Activity Co-ordinator works between the hours of 13:00 and 17:00 Monday to Friday. The Area manager said that the Activity Co-ordinator shares her time between the two units daily, activities included skittles, activities involving music, entertainers coming into the home and bingo. Residents have the use of a company minibus for outings. Recent trips have included Seaton Carew and Saltburn. Residents spoken to during the inspection said that daily activities provided by the home were limited. Residents spoke of skittles, however said that little else was carried out on a daily basis. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 13 One resident said, “ I’m bored I would like to play dominoes or darts” another said, “I get bored there’s no bingo. I used to call out the bingo at another home I was in. I would like to play cards or dominoes” another resident said, “I play skittles and I am pretty good at that, but that is all we do”. Interviews with residents and staff informed that residents were not enabled to take responsible risks. Two residents spoken to during the inspection said that they would like to go out independently, however had been informed by the Manager that they could not do so unless they were accompanied by staff. This was pointed out to the Area Manager at the time of the inspection who said that she was aware of the situation and was in the process of highlighting residents who wanted to go out on their own and who were able, completing risk assessments and supporting residents to do so. One comment card received in respect of the service stated, “No outings for residents, they just sit and vegetate, same chairs every day”. Residents spoken to during the inspection said that contact with family and friends is encouraged and that visitors are made to feel welcome at any time. The Area Manager said that the home support residents to practice their religion and that visits from clergy are available to the home, residents spoken to confirmed that this was the case. Residents interviewed spoke of flexibility in routine and freedom of choice. Menus were available in the home environment for examination. The Area Manager said that although there is no official second choice of menu available at each mealtime, salads and jacket potatoes were readily available and that the home would try and accommodate any resident request. Records were available to confirm that appropriate temperature checks are carried out on fridge, freezers and food. Records of food provided were available for inspection. One resident spoken to during the inspection said, “The food is good. The fish and chips today were good, proper fried fish with batter”, another said, “The food’s ok. I have no complaints, I think I would get choice if I didn’t like what was on the menu”, another said, “The food is good everything is good you can have more if you want. You are sometimes given a choice”. One resident said, “The food is not too bad, you have you main meal on a lunch time. On an evening you only get small sandwiches which is not enough until 08:00 the next morning”. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 14 Comments in respect of the food provided were fed back to the Area Manager at the time of the inspection. She stated that the home was in the process of a menu change. She stated that residents are provided with breakfast, lunch, tea and also received a supper. The Area Manager said that mealtimes in the home are to change to reflect the needs of the residents. One comment card received from a resident stated, “Sometimes the meals are a bit repetitive, a bit more variety would be nice. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome in this area is adequate. Residents are confident that complaints are taken seriously and will be acted upon. Minor amendments are required to be made to the home’s complaint policy. Adult protection procedures are in place, which help protect residents from abuse. Staff were aware that they needed to report any incident of abuse to the management of the home, however were not aware of procedures that followed. EVIDENCE: A complaints policy procedure was available for inspection. The home’s record of complaints in the last twelve months was not available for inspection. The Area Manager was able to describe the process of dealing with a complaint and provided a blank complaint template on which complaints would be recorded. Residents spoken to during the inspection said that they felt that any concern/complaint would be taken seriously and acted upon. The home has an adult protection policy/procedure in place, which includes a flow chart of action that staff should take if abuse is suspected. The Area Manager said that this was currently under review. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 16 The manager said that staff receive adult protection commencement of their employment and at regular intervals. training on Residents spoken to during the inspection said that they felt safe living at the home. During the inspection three staff were interviewed all of who would inform the management of the home of any incident of abuse, however were not aware of procedures that followed. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The quality outcome in this area is adequate. Cleveland View is homely, comfortable and generally well maintained. Deep cleaning or replacing the carpets and re-decoration of certain areas would further enhance this. Consideration should also be given to the locked bedroom doors on the first floor of the home and the smoking area for residents. EVIDENCE: The Area Manager accompanied the Inspector on a tour of the home. In general the home was observed to be fairly well maintained, homely with appropriate and comfortable furnishings provided. The ground floor of the home has a large communal lounge area and an adjoining quiet lounge, which is a designated smoking area for residents. It was observed that the adjoining quiet lounge/smoking area did not have a dividing door to the main lounge area and as such cigarette smoke was filtering through to the main lounge area. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 18 One comment card received from a relative stated, “A buzzer should be fitted to the smoke room, mam has had a few accidents which is upsetting for her and us”. The same relative also pointed out that the designated smoking area would benefit from an extractor fan, as it is cold in the winter when windows are open. This was pointed out to the Area Manager at the time of the inspection who said that she was in the process of receiving estimates for a dividing door and if the door were to be fitted, the lounge would require an additional call bell. The carpet in the communal lounge areas was observed to be stained and in need of deep cleaning or replacement. Bedrooms on the ground floor of the home visited during the inspection were individual and personalized. Corridor carpets on both the ground and first floor of the home were stained and in need of deep cleaning or replacement. Corridor walls on both floors of the home would benefit from painting. The dining room on the ground floor of the home was spacious, light and comfortably furnished providing residents with a pleasant environment in which to eat. The first floor of the home was observed to have an unpleasant odour in parts. The lounge carpet was stained and in need of deep cleaning or replacement. Bedrooms were well maintained and personalised. It was observed that a number of the residents doors were locked the reason given by staff was to stop other residents from entering the bedrooms. Staff during interview said that residents could go to their own rooms at any time if they asked a staff member, however quickly realised that not all residents would be able to ask and should have freedom of choice to go to their own room when they liked. The Area Manager said that she was in the process of discussion the situation of the locked doors with staff. The dining area on the first floor of the home was spacious and light, however not as pleasing to the eye as the dining room on the ground floor of the home. A comment card received from a relative at the home stated, “The carpets throughout the home are stained”. This same relative commented that the standard of hygiene in the home was not as good as it should be. A number of bolts were observed to be in place on numerous doors throughout the home. The bolts were on the exterior of the door at the top. The Area Manager was advised that this was not an acceptable locking system and must be removed and replaced if necessary with an appropriate locking system. On the day of the inspection the home was observed to be generally clean, however odours were noted on the first floor of the home. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 19 There is a large enclosed garden area for resident use. On the day of the inspection some residents were observed to be enjoying the morning sun. To the front of the home there is an area of fenced overgrown land. Appropriate laundry facilities were in place. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality outcome in this area is good. Robust recruitment procedures are followed. Staff receive induction training and a rolling programme of mandatory training is provided for staff, however steps must be taken to ensure all staff attend regular mandatory training. EVIDENCE: Staff duty rotas were available for examination during the inspection. Staffing rotas examined for the older persons unit on the ground floor showed that there was senior care assistant on duty between the hours of 08:00 and 21:00 in addition three care assistants during the day and two on an evening. Staffing rotas examined for the dementia unit on the ground floor of the home showed that there was a senior care assistant on duty between the hours of 08:00 and 21:00 in addition three care staff on a morning, four care on an afternoon and two care staff on an evening. Each unit had two care staff on night duty. Five comment cards form relatives informed the Inspector that they did not always think that there were sufficient staff on duty. The one comment card received from a resident said that staff were usually available when you needed them. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 21 The Area Manager said that she felt that staffing levels at the home were appropriate to meet the needs of residents and that staffing levels had been maintained at a higher level despite the fact that the home was not fully occupied. The Area Manager said that 45 of care staff are trained to NVQ level 2 with a number of other staff working towards the qualification. Three staff files were examined at random during the inspection. Files examined confirmed that a thorough recruitment procedure had been followed, however staff files need to be updated to include a recent photograph of the staff member. One of the three files examined had a record of induction training on file the other two did not. The Area Manager said that inductions had commenced, however were with the care staff members concerned. Records were also available to confirm that a rolling programme of training is provided for staff working at the home. A training matrix is kept, which lists all mandatory and other relevant training to the job that staff do. The matrix highlights each staff member working at the home, training received and training that is due. Records examined during the inspection highlighted that a number of staff required an update in moving and handling, fire training and first aid. Three care staff were spoken to during the inspection. One staff member said, “There is always some sort of training going on”. Staff spoke knowledgeably about the residents that they cared for and were able to give examples of good practice that they followed. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality outcome of this area is good. In general the residents health, safety and wellbeing is promoted, however, some mandatory training of staff is out of date The home seeks the views of residents, families and staff to ensure that it is managed with their best interest. Systems are in place to ensure resident’s money is managed appropriately. EVIDENCE: The Manager Joanne Britton has worked in the social care environment for many years. The Manager is a Registered General Nurse who has also gained a management qualification. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 23 The home operates an effective system in which they look after the personal allowance of a number of residents. Accurate records of transactions and receipts were available for examination. Appropriate quality assurance and quality monitoring practices are in place; residents and relatives meetings are carried out on a regular basis. The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the home’s fire extinguishers, fire alarm system and electrical wiring are serviced on a regular basis. At the time of the visit, records were not available to confirm that the home’s central heating system and boilers had been serviced, however, evidence has since been forwarded to confirm that a recent service has taken place. The Windows in the home environment are restricted to ensure safety for the people living there. Water temperatures are taken on a regular basis by the home’s handyman to ensure that they are within safe limits. Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 N/A 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 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 View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 23(2)(l) Requirement Storage The registered person must ensure that medicines are stored at the temperatures required by the manufacturers. Storage The registered person must ensure that risks to residents from unattended insecure medicines are eliminated. Medicines policies The registered person must ensure that policies and procedures for defrosting medicines fridges detail a way to keep medicines at the required temperature during the process. Administration The registered person must demonstrate staff competency in the accurate measurement of liquid preparations. Training The registered person must access appropriate training of DS0000059270.V301224.R01.S.doc Timescale for action 01/08/06 2. OP9 13(4)(c) 14/07/06 3. OP9 13(2) 14/07/06 4. OP9 13(2) 14/07/06 5. OP9 18(c)(i),1 3(2) 20/06/06 Cleveland View Care Home Version 5.2 Page 26 staff in the safe handling of medicines and staff must be assessed as competent. This was an immediate requirement. 6. OP9 13(2) Medicines policies The registered person must review policies and procedures for ordering and receiving medicines, and for monitoring current stocks to ensure that residents always receive the medicines they need on time. Records The registered person must ensure that all medicines that leave the service and are disposed of are recorded. Records The registered person must ensure that all reasons for nonadministration are documented. Administration The registered person must ensure that medicines are administered as prescribed. Records The registered person must ensure that hand-written medication administration records are accurate and are signed, checked and dated. Storage The registered person must discuss the following issues with the supplying pharmacy Over-labelling of medicines that were supplied previously Administration records that are provided by the pharmacy that DS0000059270.V301224.R01.S.doc 14/07/06 7. OP9 13(2) 14/07/06 8. OP9 13(2) 14/07/06 9. OP9 13(2) 14/07/06 10. OP9 13(2) 14/07/06 11. OP9 13(2) 14/07/06 Cleveland View Care Home Version 5.2 Page 27 state a supply of medicines was made when none was in fact supplied. 12. OP9 13(2) Controlled drugs The registered person must ensure that all controlled drugs are recorded appropriately. Storage The registered person must ensure that medicines are not transferred from the original dispensed pack to another pack. Administration The registered person is required to ensure that there is a safe system for managing warfarin to ensure that blood tests are followed up on the same day and that dosage changes are recorded in a safe manner and implemented promptly, and are easily tracked. The home must keep accurate medication administration records. This is outstanding from the last inspection held on 28 June 2005. The woodwork, behind the baths must be painted. (Previous timescale for action of 28th June 2005 not met) The Registered Person must ensure that resident assessments are developed further and include a detailed assessment of needs Care plans require further development to include • Cleveland View Care Home 14/07/06 13. OP9 13(2) 14/07/06 14. OP9 13(2) 14/07/06 15. OP9 13 13/06/06 16. OP19 23 31/08/06 17 OP3 14 30/09/06 18 OP7 OP8 14, 15 30/09/06 Following an assessment of Version 5.2 Page 28 DS0000059270.V301224.R01.S.doc a resident a plan of care must be developed for each individual problem/medical condition • Care plans must clearly identify the problem, goal and action/care that is required to manage the problem/medical condition Care plans must clearly state capabilities, limitations and assistance required by the resident Care plans must be evaluated individually on a monthly basis or more often if required. Evaluations must include any deteriorations or improvements made Care plans must be drawn up with the resident where able and signed by the resident or representative. This also applies to reviewing the plan of care Risk assessments require further development. The Registered Person must identify residents at risk, develop/update a risk assessment. Risk assessments must be reviewed and updated on a regular basis to confirm effectiveness. Risk assessments require further development to include specific preventative measures to reduce/prevent identified risk from occurring/reoccurring 21/07/06 • • • • 19 OP8 13, 16 The Registered Person must ensure that equipment required DS0000059270.V301224.R01.S.doc Cleveland View Care Home Version 5.2 Page 29 for the promotion of tissue viability and prevention/treatment of pressure sores is provided 20 OP12 OP14 13 The Registered Person must enable residents to take responsible risks. A risk assessment must be undertaken on those residents who want to go out independently to determine if it is safe to do so. Residents must be supported to take responsible risks The Registered Person must consult with residents/families and plan a varied/suitable plan of activities and outings for residents residing at the home The Registered Person must consult with residents regarding food provided at the home. An alternative choice must be available to residents at each mealtime The home’s record of complaints must be available in the home for inspection Staff must be appropriately trained in respect of adult protection • The Registered Person must determine if there is a need to fit an adjoining door between the main lounge area and adjoining lounge designated for those residents that wish to smoke. The Registered Person must consult with the Fire Authority The Registered Person must determine if there is Version 5.2 Page 30 30/08/06 21 OP12 16 30/08/06 22 OP15 16 30/08/06 23 OP16 22 21/07/07 24 OP18 13 30/08/06 25 OP19 13, 16, 23 30/09/06 • Cleveland View Care Home DS0000059270.V301224.R01.S.doc a need to fit an extractor fan and call bell to the designated smoking area for residents • Carpets in communal lounge and corridor areas must be deep cleaned or replaced Bolt locks on exterior doors must be removed. If required, bolt locks must be replaced with an appropriate locking system. 21/07/06 • 26 OP19 13, 16, 23 The Registered Person must review the situation of locking residents bedroom doors on the first floor of the home 23 19 The odour on the first floor of the home must be eliminated Staff files must be updated to include a recent photograph of the staff member The Registered Person must ensure that all staff receive regular mandatory training 27 28 OP26 OP29 31/08/06 30/10/06 29 OP30 OP38 13, 18 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP28 Good Practice Recommendations The corridor walls on the ground and first floor of the home would benefit from painting The home should continue with working towards achieving 50 of care staff trained to NVQ level 2 in care Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cleveland View Care Home DS0000059270.V301224.R01.S.doc Version 5.2 Page 32 - 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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