Care Home: Clevedon Court Residential Home

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What the care home does well There clearly has been a real effort from the manager and staff to address the shortfalls we identified at our last inspection. Staff despite their disappointment of the quality rating being made Poor have a real commitment to the home and strive to provide a service which meets the needs of those living in the home. Individuals we spoke with were all very positive about the approach of staff “all very good and caring” “they are there when we need them” “very caring”. It is noted from this inspection that the home is more pro-active in the involvement of community nurses and other health professionals where there are concerns regarding individuals health needs. Care planning is of good standard with improved information and detailed tasks being recorded and identified by care staff. Introduction of key worker has also led to improved recording and communication of individuals needs. Staff commented that they felt “more valued” and “there is better structure”. Individuals we spoke with told us that staff “have the time to spend with us” and “get to know us”. Comments received by the home included: “I go to a lot of care homes and I feel this is one of the nicest and friendliness, it’s always clean, nice caring atmosphere and does not smell”. (from paramedic) Staff told us in their response to our Have Your Say questionnaire when asked What Does the home do well? Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 “The home provides quality care to the residents as well as giving the staff all the training which we need to uphold the quality of care. It is a warm and welcoming home”. “There is always a warm friendly atmosphere in and around the home. The home works as a team, there is good communication between service users and staff.” “We have very good standards of care for our residents and good standards of hygiene. We work well as a team. In this home our motto is Caring Hands Caring Hearts”. What has improved since the last inspection? The last inspection identified a number of areas which required improvement and resulted in the home being given a Poor quality rating. We examined all the requirement made at the last inspection and found that substantive improvements have been made: All individuals now have moving and handling assessments which identify equipment to be used. It is noted and the manager was advised that these need to be improved further by clearly stating the tasks, associated equipment and actions staff to undertake to make sure moving and handling is achieved in as safe a manner as possible. Assessments are now in place regarding skin integrity and nutritional needs of individuals living in the home. Equipment in use is regularly monitored and maintained as required so that risk of harm to individuals or staff is alleviated. Medication practice has improved with audits of administering records to identify where there may be gaps in recoding. The use of pots to administer medication specifically at breakfast time is no longer practiced and all medication is administered directly from dossette containers. No individuals currently refuse health treatment and all those who require such treatment are receiving it on a regular basis. The acting manager is due to undertake Safeguarding training on the 14/12/09 and staff have completed training in a number of areas including medication and infection control (due 25/11/09). Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 There is on going improvements in the environment of the home, fire safety has been addressed with new fire system in place and all rooms linked to fire alarm. What the care home could do better: We have identified from this inspection that the home must improve in the area of risk assessment and make sure that there is clear guidance and instruction too assist staff in responding to potential risk. This specifically related to individuals in the home who have a catheter and being more explicit in completing moving and handling risk assessments. Further in recruiting staff application forms must contain all the necessary information regarding the applicant specifically a full employment history. This will enable the manager to make an informed judgement, along with other information, about the suitability of the potential employee. Finally the manager must review the first aid training for staff and availability of staff who have first aid training. This is to make sure that at all times there is a member of staff who has completed this training. The CQC provide guidance about first aid training and availability of first aid trained staff on their website cqc.org.uk. Key inspection report CARE HOMES FOR OLDER PEOPLE Clevedon Court Residential Home 1-3 Clevedon Road Weston Super Mare North Somerset BS23 1DA Lead Inspector John Clarke Key Unannounced Inspection 19th November 2009 09:00 DS0000070055.V378592.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clevedon Court Residential Home Address 1-3 Clevedon Road Weston Super Mare North Somerset BS23 1DA 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) 01934 621981 01934 621981 ANJ & ASH Care Ltd Ms Jacqueline Kendrick (as of 5th December 2009) Care Home 22 Category(ies) of Learning disability (3), Old age, not falling registration, with number within any other category (22) of places Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) 2. Learning disability (Code LD) - maximum of 3 persons The maximum number of service users who can be accommodated is 22. Date of last inspection Brief Description of the Service: Clevedon Court provides personal care for up to 22 people elderly people. The home also cares for 3 elderly people with a learning disability. Clevedon Court is set just off the sea front, with level access to the town centre. All bedrooms have en-suite facilities, and two of the en-suites have bathing facilities. There are 21 bedrooms, one of which may be used as a double. At present, all are being used as singles. All bedrooms meet the new spatial standards and many exceed them. There is a passenger lift accessing both sides and both floors of the home, and a stair lift, which accesses three bedrooms on a mezzanine floor. The mezzanine level is also accessible via a ramp. The provider makes information available through a brochure and information pack. The information pack contains the Statement of Purpose and Service User guide and all relevant information about the home. The fee is £382.64 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. Clevedon Court Residential Home DS0000070055.V378592.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 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection too look at the service response to requirements made at our last inspection which rated the service as Poor. We looked at a number of records relating to the quality of the service including pre-admission assessment, care plans, medication administering records and storage, staff recruitment and training and health and safety. We were also able to discuss with a number of individuals living in the home their experience and views of the service they receive. We also spoke with staff about the service they provide and relatives who were visiting the home at the time of our inspection. What the service does well: There clearly has been a real effort from the manager and staff to address the shortfalls we identified at our last inspection. Staff despite their disappointment of the quality rating being made Poor have a real commitment to the home and strive to provide a service which meets the needs of those living in the home. Individuals we spoke with were all very positive about the approach of staff “all very good and caring” “they are there when we need them” “very caring”. It is noted from this inspection that the home is more pro-active in the involvement of community nurses and other health professionals where there are concerns regarding individuals health needs. Care planning is of good standard with improved information and detailed tasks being recorded and identified by care staff. Introduction of key worker has also led to improved recording and communication of individuals needs. Staff commented that they felt “more valued” and “there is better structure”. Individuals we spoke with told us that staff “have the time to spend with us” and “get to know us”. Comments received by the home included: “I go to a lot of care homes and I feel this is one of the nicest and friendliness, it’s always clean, nice caring atmosphere and does not smell”. (from paramedic) Staff told us in their response to our Have Your Say questionnaire when asked What Does the home do well? Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 Page 6 “The home provides quality care to the residents as well as giving the staff all the training which we need to uphold the quality of care. It is a warm and welcoming home”. “There is always a warm friendly atmosphere in and around the home. The home works as a team, there is good communication between service users and staff.” “We have very good standards of care for our residents and good standards of hygiene. We work well as a team. In this home our motto is Caring Hands Caring Hearts”. What has improved since the last inspection? The last inspection identified a number of areas which required improvement and resulted in the home being given a Poor quality rating. We examined all the requirement made at the last inspection and found that substantive improvements have been made: All individuals now have moving and handling assessments which identify equipment to be used. It is noted and the manager was advised that these need to be improved further by clearly stating the tasks, associated equipment and actions staff to undertake to make sure moving and handling is achieved in as safe a manner as possible. Assessments are now in place regarding skin integrity and nutritional needs of individuals living in the home. Equipment in use is regularly monitored and maintained as required so that risk of harm to individuals or staff is alleviated. Medication practice has improved with audits of administering records to identify where there may be gaps in recoding. The use of pots to administer medication specifically at breakfast time is no longer practiced and all medication is administered directly from dossette containers. No individuals currently refuse health treatment and all those who require such treatment are receiving it on a regular basis. The acting manager is due to undertake Safeguarding training on the 14/12/09 and staff have completed training in a number of areas including medication and infection control (due 25/11/09). Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.2 Page 7 There is on going improvements in the environment of the home, fire safety has been addressed with new fire system in place and all rooms linked to fire alarm. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Clevedon Court Residential Home DS0000070055.V378592.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 Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make an informed decision about the capacity of the home to meet health and social care needs. EVIDENCE: We looked at a pre-admission assessment undertaken by the home and it contained limited information about the health and social care needs of the individual. The home obtains a copy of the local authority care assessment where this has been completed. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 10 It is noted that subsequent to the inspectors first visit the home introduced an improved more through assessment which provides the necessary information including mental health, physical disability and daily routines. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care Planning and arrangements for meeting health care are generally good providing staff with the necessary information so that the health and social care needs of residents are met. Arrangements for managing resident’s medication make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld. EVIDENCE: We looked at five care plans all of which had good information identifying needs and actions regarding physical health, mobility, leisure and hobbies, meals and diet, mental health, continence. It is noted that a paramedic remarked in the comments book “nice to see care plans with all the Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 12 information in”. Monthly reviews had been undertaken and key worker (this having been introduced since the last inspection) comments. Assessments regarding moving and handling, nutritional needs and pressure care had been completed and reviewed. Risk assessment were completed regarding falls but for two individuals who have a catheter there was no risk assessment. One individual who was assessed at high risk regarding nutrition had been reviewed and it was noted “diet reviewed and adjusted” but no detail as to the changes that had been made as result of this review. We looked at daily records for information about access to health services and found that individuals had received chiropody treatment, optician and for one person a referral had been made to the continence advisor for an assessment. The manager confirmed that there are currently no individuals refusing health treatment. We spoke with an individual living in the home and they told us that they can “see my doctor when I want only have to ask”. We looked at the arrangements for the managing of medication and found that there is secure storage and administering records for a period of 4 weeks showed no gaps in recording. The manager advised that they undertake regular audits of administering records. Staff have undertaken medication training and this was confirmed by staff training records. Controlled drugs are recorded in a Controlled Drug register and signed by two staff members. Stock was checked and found to be as recorded and storage is in a separate secure cupboard. As part of individuals care plan a medication profile is completed. A number of these were looked at and it was noted that in one instance it was not accurate and needed updating. We discussed with the manager their use and importance of making sure they are dated and accurately reflect the medication being administered to the individual. We spoke with individuals living in the home about the approach of staff particularly if they felt their privacy was respected. One individual who spends most of their time in their room told us “I am always treated with respect and all of the staff treat me well” “they respect my privacy”. They confirmed to us that staff always knock before entering the room. We also observed staff when entering individual’s rooms and when supporting individuals this was done in a sensitive and supportive manner. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. Meals are provided which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: Individuals we spoke with said there was “enough going on” “I like just having a chat” when we asked about activities in the home. Included are outside entertainers, film nights and games. Individuals with the support of staff visit a community centre for older people every week. There is a notice board outside the communal lounge giving information about activities and social events in the home. A hairdresser visits the home weekly and this has become more of a Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 14 social occasion in that the home has made one room (formally the smoking room) on the ground floor into a hair salon. Previously individuals had their hair cut in their rooms one individual told us “it’s much nicer now”. At the time of our visit there was a display of goods for sale giving individuals an opportunity to buy Christmas presents. Individuals we spoke with told us that they are able to have visitors at any time. One individual told us that staff “are very friendly here and always make people welcome”. We also spoke with relatives who were visiting the home and they told us that the “home is welcoming” “staff all very friendly” and “they let us know about how our relative is and any concerns”. Another visitor said they felt the service had improved particularly in regard to the environment. A relative who responded to our Have Your Say questionnaire said “the staff are always so helpful whenever I call”. We asked individuals about the meals provided in the home and we were present when the main meal was served. People told us they “enjoyed the food” “always nice”. One individual “it’s very good and if there’s something I don’t like there’s always something else I can have”. We looked at the menus and they were varied and provided good choice. On the days we visited the meals were well presented and looked appetising. The menu for the day is displayed on the home’s notice board. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clear procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. As far as possible individuals who live in the home are protected from harm by having a policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: At our last inspection it was noted that individuals we spoke with were aware of being able to make a complaint but also said that they would discuss with staff any worries or concerns they had about the care they receive. No complaints have been made since our last inspection. Since our last inspection staff and manager have undertaken Safeguarding training and the manager is due to attend further training for managers. In discussion with the manager it was reiterated that her responsibility when there is any allegation or concern about abuse is to make the individual safe and inform the local Safeguarding team. Staff we spoke with were clear about Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 16 their actions and felt confident in reporting any concerns they may have about individual’s welfare. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe and hygienic environment for people who live there. People who live and work in the home benefit from a warm, welcoming and improving homely environment. EVIDENCE: Since our last inspection it is evident that improvements in the environment of the home have been made with communal areas and individual rooms being decorated and the lighting has been improved. The room previously used by smokers has been decorated and is now a hairdressing salon and a new smoking covered area has been provided at the rear of the home. There is an Environment Improvement plan in place which identifies further re-decoration of communal areas, lounge and dining room. The garden area at Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 18 present has open access and doesn’t provide a safe enclosed area. This has been identified as requiring improvement and we were advised that this will be addressed over the coming year. Concerns regarding fire safety have been addressed with improved fire system and all rooms are now directly linked to the fire system. All areas of the home which were seen during our visit to the home were clean and individuals we spoke with commented on the “cleanliness of the home”. There are infection control measures in place such as use of hand cleaning gels and protective clothing is available. We spoke with staff about their practice around infection control and they were able to set out good practice in this area of care. The majority of staff have now undertaken infection control training. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. Training of staff has improved with a system now in place to monitor and review staff training needs. The failure to have first aid trained staff on duty at all times potentially places the health and welfare of individuals at risk. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected however to fully protect individuals in the home a full and detailed employment must be obtained. EVIDENCE: We looked at staffing worked timesheets for a period of 4 weeks. They showed that generally there are 3 care staff on duty AM, 8-1/8-2/8-4 AND 2 pm 2-8 with two waking night staff 8-8. In addition the manager is on duty and there is a senior on duty on all shifts. Following concerns passed to us at the previous inspection regarding the practice of night staff the manager has Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 20 undertaken a number of spot checks and evidence of these were seen. The manager advised that night staff have received a salary increase and that there is no question that both staff members are to remain awake at all times during their shift. We looked at recruitment and selection records for 5 members of staff 4 of whom have been recruited since our last inspection. We found that Criminal Record Bureau and POVA1st checks had been completed and two references obtained for all of the individuals. Application forms for all but one provided the necessary information regarding employment history. For one individual the application form had not been fully completed and there was no employment history. Training records for 6 members of staff showed they had completed “mandatory” training: moving and handling, Safeguarding and Health & Safety (as part of induction). All staff have completed medication training and the majority of staff have now undertaken Infection Control training. The manager is due to complete Mental Capacity Act and seniors are also to undertake this training. A training audit is now in place to clearly identify training completed by staff and required updates. The company have employed a training consultant to undertake all of the homes training thereby improving the availability of training too staff. Other training completed by staff included Dementia Awareness, Skin Integrity and Food Hygiene We also looked at night staff training, specifically first aid, and found there are two staff members who have worked on the same shift who have not had this training. Of the 5 night staff 3 have no first aid training. We asked staff in our questionnaire: Are you being given training that is relevant to your role and helps you understand and meet the individual needs of people? All the respondents said Yes and one staff member commented: “I feel the home does well on training their staff and offer several courses for the staff to participate. There are always updates on new courses and fresh information to keep us updated.” Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good opportunities for individuals who live in the home and others to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of residents and staff is protected. EVIDENCE: The acting manager of the home has previously managed a care home for twelve years so has extensive experience of working in this setting. She has been in post at Clevedon Court since March 2009. Individuals we spoke with were positive about her approach; “friendly you can talk to her” “always Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 22 around” “she is making things better”. Staff described her as “approachable someone you can always go to if you need to know anything”. Staff told us that morale at the home was good and “has improved with her here”. We received five responses from staff too our Have Your Say questionnaire and all said that they “Regularly” receive support from the manager and meet to discuss how staff are working. We looked at a limited number of questionnaires which had been completed by individuals living in the home and relatives. They were all positive about the quality of the care provided at Clevedon Court. However we discussed with the manager that they need to look at having residents meeting to provide an opportunity for individuals to make suggestions and comment on the care they receive. A comments book is available and we looked at entries which included: “lovely friendly atmosphere” “super staff group” (from relatives). We looked at Fire safety records which confirmed that the necessary fire tests and emergency lighting tests take place. Staff have received regular fire drill training. The fire safety officer visited the home on the 7th October 2009 and was satisfied with all the work that had been undertaken to remedy the shortfalls identified by a previous safety check. Records are now being held and completed regarding checking and maintenance of equipment in the home including bed rails. Water temperatures are taken weekly and staff record water temperatures when giving baths. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 23 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? NO 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 13 (4) © Requirement The manager to make sure that unnecessary risks to the health and safety of individuals living in the home are identified and so far as possible eliminated. This relates to undertaking risk assessments for individuals who have a catheter to identify potential health risks and actions to be taken by staff to alleviate and respond to any concerns. Risk assessments too specific state guidance and details of actions to be undertaken by staff in supporting and assisting individuals. The manager to make sure that the care is conducted so as to promote and make proper provision for the health and welfare of individuals living in the home. This relates to having full and detailed employment history for potential employees so that this forms part of the information to make a decision about the suitability of the individual. Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 25 Timescale for action 30/12/09 2 OP29 12 20/11/09 3 OP30 18 The manager to make sure there 31/01/10 are at all times suitably qualified, competent and experienced persons working at the care home in such numbers as are appropriate for the health and welfare of individuals living in the home. This relates to having the required level of first aid trained staff available to work at the home and making sure there is a first aid qualified member of staff on duty at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clevedon Court Residential Home DS0000070055.V378592.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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