Inspection on 11/05/06 for Cavell Lodge

This inspection was carried out on 11th May 2006.

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

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

Other inspections for this house

Cavell Lodge 30/10/07

Cavell Lodge 29/05/07

Cavell Lodge 28/09/05

Cavell Lodge 20/05/05

Cavell Lodge 07/03/05

Cavell Lodge 25/10/04

Cavell Lodge 02/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Cavell Lodge 5 Blenheim Chase Leigh On Sea Essex SS9 3BZ Lead Inspector Sarah Buckle Unannounced Inspection 11th May 2006 10:45 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 Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cavell Lodge Address 5 Blenheim Chase Leigh On Sea Essex SS9 3BZ 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) 01702 480660 01702 474316 Corvell Health Care Limited Manager post vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (36) of places Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Total number of service users for whom personal care is to be provided shall not exceed 36. Personal care can be provided for up to 36 older people over the age of 65 years of age, Personal care can be provided for up to 6 older people who have dementia and are over 65 years of age. 28th September 2005 Date of last inspection Brief Description of the Service: Cavell Lodge provides care and accommodation for thirty-six older people of whom up to six may suffer from dementia. The home particularly caters for residents with medium to low dependency needs. The home is purpose built and provides a high standard of accommodation. There are thirty-two single rooms and two double rooms situated on three floors of the home. All rooms have en-suite facilities. There is access to all floors via a passenger lift. Residents have a choice of several pleasant lounges plus an attractive dining room. The home also has a small quiet lounge, a visitors’ room and a hairdressing salon. There is a large well-maintained garden for residents to use and a large summerhouse. Off road parking is available. The home is situated close to a bus route, in a residential area, and is close to local parks and woodland. The current weekly fees for residents living at Cavell Lodge range from £400 to £510. Residents pay additional costs for hairdressers, chiropody and newspapers. This information was provided on 16/05/06. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced site visit on 11th May 2006, which took place over six hours and a second unannounced site visit on 05/06/06, which took place over three hours. In order to undertake this inspection, evidence has been accumulated from a number of sources. An inspection record has been compiled taking into account any notifications that have been received since the last inspection, any correspondence and matters arising from the previous inspection report. A pre-inspection questionnaire was sent to the home however this was not returned to the Commission prior to the inspection and is still outstanding. Records, care plans and other significant documents were examined. Ten residents completed “Have your say about……” surveys during the site visit. The residents within Cavell Lodge were observed within their home environment and two of them were spoken with in some depth. The acting manager was also spoken with, as were two staff members. What the service does well: What has improved since the last inspection? Since the last inspection there have been no obvious improvements to the service. An acting manager has recently taken over the running of Cavell Lodge. She is currently in the process of completing her registration for application as manager with the Commission. The acting manager is undertaking the NVQ4. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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 Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Pre-admission assessments are inadequate. EVIDENCE: Two care plans were sampled in depth. One contained a COM5 from the relevant social services department outlining briefly the needs of the prospective resident. The second care plan contained no pre-admission assessment documentation. Two care staff and the acting manager were spoken with and no one could say for certain how many people within the home were suffering from dementia. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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, 9, 10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Individual care plans were inadequate. Medication is not well managed but had improved significantly by the second site visit. Residents’ privacy and dignity is not respected at all times. Last wishes were not satisfactory. EVIDENCE: Two care plans were sampled in depth. These were completed to varying degrees, but neither contained detailed or instructive support plans. Where information was available regarding the needs of the resident, it was scant i.e. in relation to one resident’s medication needs the plan stated “(He) has diabetes, as to which he has insulin daily to control”. There were no current reviews noted and no comprehensive risk assessments. One social services assessment examined during the site visit stated that one of the care plans sampled was incomplete, unsigned, undated and not reviewed and that risks remained unidentified. It also stated that the residents’ blood sugar levels and her weight had not been monitored. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 10 It was positive to note that new care plans are in the process of being developed. The treatment room was disorganised, with medication, dressings and stoma bags stored inappropriately. MAR sheets had handwritten medication profiles, which were not signed or counter signed. There were a number of omissions seen on the medication records. PRN protocols were not in place within the medication file. During the examination of the medication process it was noted that one resident was signed up for medication on her MAR sheet, which had not been signed for. This medication was not contained within the cassette and there was no information in her care plan in relation to the medication. On speaking with the resident it transpired that she was self-administering some of her medication. This information was not seen to be recorded anywhere and no risk assessment had been undertaken. On the second site visit, it was positive to note that the medication process had improved. The treatment room had been organised, historical MAR sheets filed according to the room number of the resident and medication specific policies and procedures placed in files within the room. An audit trail was made possible by these structures being put in place. There were still a number of omissions within the MAR sheets, and handwritten or altered medication profiles that had not been countersigned. In relation to privacy and dignity, the home has a procedure in place whereby information in relation to all residents is contained within a bound A4 book called the ‘Seniors Handbook’. The residents are listed by room number within the book and are often not referred to by name i.e. on 15/03/2006 one room number was noted as requesting a GP visit regarding a rash another said “social worker here for annual review” and on 22/04/06 it stated “24/ Daughter visited and went for a walk for a while; 1/ Visited by son; 20/ Had visitor”. On 23/04/06 the book stated that one resident was very constipated and that another resident “poohed in her room and along the corridor and the bathroom next to her room”. On the second site visit an Immediate Requirement notice was served in relation to the ‘seniors handbook’, which was found to still be in use within the care home, and to contain private information about residents listed in a manner that breached regulation in relation to privacy and dignity. No information regarding last wishes was seen in either of the care plans sampled. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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): 12, 13, and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Recreational, social and religious activities are inadequate within Cavell Lodge. Family links are encouraged. The residents receive a balanced diet. EVIDENCE: Recreational and social needs of residents are not clearly identified within care and support plans, however, one of the care workers spoken with stated that there are a number of organised activities for residents to partake in. These include the mobile library visiting the home, a hairdresser visiting the home, a sing-a-long with local vicar and bingo. The acting manager said that she is organising a coach trip for residents. One of the residents survey returned to the Commission stated, “I love bingo!” others stated that they prefer to watch TV and relax, or prefer their own company, or that they liked their books and crosswords. However, during the course of the site visit, a lot of residents were observed to be spending their time sitting in a lounge or the hallway, with little staff interaction and no meaningful activity. The minutes from the residents meeting on 23/02/06 demonstrate that the residents expressed the need for more activities. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 12 A number of family visits were recorded and one of the residents spoken with said that her daughter visits her four times each week. Four weeks of menus were examined as part of the key inspection. The residents at Cavell Lodge receive a balanced diet and a choice of dinner. One resident spoken with said that she enjoys the food, can leave what she doesn’t like, gets a choice and that she likes the puddings. Eight of the surveys returned to the Commission stated that they usually like the food. One resident commented that they wished they could eat their meals in peace, as there is always a lot of noise. Two residents stated that that always like the meals at the home. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 13 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedure is adequate. Residents are not adequately protected from potential harm and abuse. EVIDENCE: All of the residents surveys returned to the Commission stated that they were aware of how to make a complaint. Four residents said they would always know how to make a complaint. One resident stated that they would complain to the acting manager, another said that they would speak to the acting manager or find out the name of the senior on duty. Two staff members spoken with stated that if they suspected the abuse of a resident they would inform the acting manager, however, there was only evidence of POVA training in one of the four staff files sampled, and no evidence of manual handling or other core training was available. Staff members who were employed prior to their CRB check being completed did not have evidence of POVA first checks in their files. There have been no Regulation 37 notifications received by the Commission since December 2005 even though during the site visit a staff member referred to a gentleman who had recently died. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 14 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment at Cavell Lodge is safe and well maintained. The home is clean and hygienic. EVIDENCE: A tour of the premises was undertaken during the site visit. The premises are comfortable and homely. There were no offensive odours detected within the home. All of the residents’ surveys stated that the home is always clean and fresh. One resident commented that the home is “very clean and tidy” and another stated “Oh yes, without any doubt, very clean”. However, no evidence was seen in relation to mandatory training in infection control. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents’ needs are in the main part met by the numbers and skills of the staff team. There was no recorded evidence to suggest residents are in safe hands at all times. The recruitment process is not robust. Induction and staff training are inadequate. EVIDENCE: Four weeks of staff rotas were examined and these demonstrated that the staff team are not currently working excessive hours. The acting manager stated that she had adjusted the shift patterns to incorporate two seniors and four care staff during the busy morning period. The residents’ surveys were full of praise for the staff team within the home i.e. one resident stated, “I’ve got no complaints about the carers, I think they are very kind and considerate”, another stated, “I am happy to be here and satisfied with the staff”. Two carers spoken with had obvious knowledge of the needs of the residents. Three of the residents surveys returned said that the staff are “very busy” and that “They can’t be everywhere at once”. There was no training information recorded in relation to the staff team, and therefore it is not possible to determine who has undertaken NVQ training at what level. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 16 Four staff files were sampled. One of these had evidence of a completed CRB check. Two staff members had begun employment prior to their CRB check and there was no evidence within their files of Povafirst checks. One file sampled was due to begin employment on 13/05/06, and had only a completed application form contained within her file. On the second site visit an Immediate Requirement notice was served in relation to recruitment, as members of staff are currently employed within Cavell Lodge without the specified CRB or Povafirst checks having been undertaken. This places residents within the home at risk of possible harm or abuse. There was no current recorded information to outline staff training that had been undertaken. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 17 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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The new manager is fit to be in charge and responsible. Supervision of staff is inadequate. EVIDENCE: A new manager has recently been appointed to the Cavell Lodge and is currently implementing changes to the running of the home. The second site visit demonstrated that she had worked hard to make appropriate changes in accordance with regulation. There was no evidence to suggest regular recorded supervision of staff members. Two care workers spoken with said that they last had supervision about six months ago. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 1 X X Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 14 1& 2 Requirement The registered person must ensure that a suitably qualified person assesses the needs of prospective residents prior to admittance to the home. This assessment must be kept under review. This is in relation to limited or no evidence of initial assessments being available. The registered person must ensure that a care plan is devised in consultation with the resident or their representative, outlining their health and welfare needs and how these are to be met. The plan must be made available to the resident and kept under review. This is in relation to individual care plans failing to identify clearly the health and welfare needs of residents, not identifying risk factors and not being reviewed and revised. The registered person must ensure that the home makes proper provision for the health DS0000015423.V291921.R01.S.doc Timescale for action 01/08/06 2. OP7 15(1) & (2) 01/08/06 3. OP8 12(1)(a) 01/08/06 Cavell Lodge Version 5.1 Page 20 and welfare of residents. This is in relation to information regarding health, welfare and medication issues not being recorded in residents care plans. The registered person must ensure arrangements are made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 4. OP9 13(2) 01/07/06 5. OP10 12(4)(a) This is in relation to omissions on MAR sheets, lack of information regarding self-administering residents, handwritten changes to medication profiles and lack of PRN protocols. The registered person must 01/07/06 ensure that the home is conducted in a manner that respects the privacy and dignity of service users. This is in relation to residents often being referred to by the number of their bedroom rather than by name and to personal information about residents being listed in a handover book. An Immediate Requirement notice was served in relation to this issue during the second site visit. The registered person must ensure unnecessary risks to residents’ health and safety are identified and eliminated. The registered person must make arrangements to prevent residents being at risk of harm and abuse. This is in relation to risk assessments being inadequate and to a lack of evidence 6. OP18 13(4)(b) (c)(5) & (6) 01/07/06 Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 21 7. OP29 19(1)(b) & Sch 2 regarding staff training in POVA. The registered person must ensure that people are not employed to work at the home unless all the information and documents specified in paragraphs 1 to 9 of Schedule 2 have been obtained. This is in relation to staff files not containing all of this specified information and to staff members being employed prior to their CRB check. An Immediate Requirement notice was served during the second site visit in relation to this issue. The registered person must ensure that the persons employed by the care home receive training and induction and suitable assistance to achieve this. This is in relation to no records of staff training being available. The registered person must ensure that persons working at the home are appropriately supervised. This is in relation to a lack of evidence regarding supervision being undertaken with staff members. 01/08/06 8. OP30 18(1)(c) (i)(ii) & 13(4) (5) (6) 01/08/06 9. OP36 18(2)(a) 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Cavell Lodge Refer to Good Practice Recommendations DS0000015423.V291921.R01.S.doc Version 5.1 Page 22 1. Standard OP31 The acting manager should complete her application for registration and return it to the Commission. Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Cavell Lodge DS0000015423.V291921.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!