This inspection was carried out on 6th December 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Cleveleys Nursing Home 19 Rossall Road Thornton Cleveleys Lancashire FY5 1DX Lead Inspector
Mrs Ruth Edgington Unannounced Inspection 6th December 2005 09:15a 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 Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 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. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Cleveleys Nursing Home Address 19 Rossall Road Thornton Cleveleys Lancashire FY5 1DX 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) 01253 865550 01253 866589 Manor Homes (Poulton) Limited Mrs Elaine Lowe Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (6), Terminally ill (6) of places Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: Up to 20 service users in the category of OP (Older Persons over the age of 65 years) Up to 6 services users in the category of PD (physically handicapped) Up to 6 services users in the category of TI (Terminally Ill) The service should employ a suitably qualified and experience manager who is registered with the Commission for Social Care Inspection. 8th June 2005 2. Date of last inspection Brief Description of the Service: Cleveleys Nursing Home is registered to accommodate a maximum of 32 elderly persons. 6 beds may be used for residents with a physical disability and 6 beds may be used for residents with a terminal illness. The home is situated in a residential area of Cleveleys and is close to local amenities and within walking distance of the seafront. The home was purpose built and the accommodation consists of 3 double bedrooms and 26 single bedrooms, 8 of which have ensuite toilet facilities. There are lounge and dining room areas on the ground and first floor and there is a no smoking policy throughout the home. A passenger lift is available and aids are provided throughout the home to assist residents as required. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was undertaken by two Inspectors. The Inspection stated at 9.15am and took place over two hours. The Inspectors looked at various records relating to the standards not looked at during the previous inspection. The Inspectors spoke generally to the staff and residents seen during a tour of the building and looked at four comment cards that had been completed by residents. The Inspectors also spoke to one relative who was visiting at the time. Since the previous inspection an additional inspection has been carried out by the Pharmacy Inspector to examine the medication policies and procedures of the home. What the service does well: What has improved since the last inspection?
The manager has now been in post for approximately nine months and has identified a number of improvements that could be made. Following advice from the Pharmacy Inspector, the medication procedures have significantly improved. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 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. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 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 Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 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): These standards were not assessed. EVIDENCE: Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 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): 9 The systems in place for the administration of medication have improved since the last inspection, however shortfalls still remain that require attention to ensure that residents are protected by the procedures carried out in the home. EVIDENCE: Following the previous inspection an additional inspection was carried by the Pharmacist Inspector, the outcome of which was that several requirements and recommendations were made. As part of this current inspection the Inspectors were able to evidence that whilst the majority of these matter had been dealt with, there were still some that required attention to ensure that the policies and procedures for the receiving and disposal of medication were being complied with. The Inspectors were informed that prescriptions were not being seen and checked by the home prior to the pharmacist dispensing the medication. Medication no longer required was not being disposed of. The Inspectors found that the manager was unsure of what to do with this medication now that it
Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 10 can no longer be returned to the chemist. Advice was given and the Inspectors informed the manager that they would ask the Pharmacist Inspector to contact her. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 11 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): These standards were not assessed. EVIDENCE: Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed. EVIDENCE: Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 13 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): 22 & 25 The standard of the environment within the home is good, providing residents with an attractive and homely place to live. Storage space is very limited and could potentially put residents at risk. EVIDENCE: A tour of the home confirmed that the home was well maintained, clean and free from any offensive odours. Radiators throughout the home have a guaranteed low surface temperature to protect the residents from the risk of burning. The hot water temperatures throughout the home are checked and delivered at a safe temperature. The Inspectors noted that storage space was very limited and on the first floor a small area previously used as a ‘nurses station’ was being use to store continent pads. The Inspectors were concerned as there was no door on this area and therefore this could pose a possible risk to the safety of the residents.
Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 14 The manager was advised that this situation should be rectified as soon as possible. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 15 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): These standards were not assessed. EVIDENCE: Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 16 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 & 35 The leadership from the manager is good and promotes a consistency of care. Additional support is needed to ensure that the manager continues to undertake her role and responsibilities fully. EVIDENCE: The manager is a qualified nurse who has many years of experience in caring for residents. The manager is aware that she must obtain a management qualification. The Inspectors were informed that she has been unable to commence training so far but that she fully intends to commence the appropriate course next year. Whilst at the time of the inspection there were sufficient staff on duty to meet the needs of the residents accommodated, the Inspectors found that often the
Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 17 manager was the only qualified member of staff on duty and therefore she had to carry out her management role in addition to nursing tasks. Since the previous inspection there has been a change in the ownership of the home. The Inspectors found that the responsible person was not undertaking monthly visits as required by Regulation 26 of the National Minimum Standards. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x 2 x x 3 x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x x Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 19 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 13(2) Requirement Timescale for action 31/01/06 2 OP22 23 3 OP31 26 The manager must ensure that medication is disposed of correctly and appropriate records are made of all medicines leaving the home. (The timescale of 11/07/05 not met) The registered provider must 31/01/06 ensure that there is suitable provision made for storage of equipment used in the home. The registered provider must 31/01/06 ensure unannounced visit to the home are undertaken at least once per month and forward a copy of their report on the conduct o home to the Commission for Social Care Inspection Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 20 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. 3 Refer to Standard OP9 OP31 OP31 Good Practice Recommendations All prescriptions should be seen and checked prior to the pharmacist dispensing. The registered manager should hold a qualification to NVQ level 4 in management. Additional support should be given to the manager to enable her to undertake her role and responsibilities. Cleveleys Nursing Home DS0000006032.V269467.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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