Inspection on 29/05/07 for Cavell Lodge

This inspection was carried out on 29th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cavell Lodge 30/10/07

Cavell Lodge 11/05/06

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 Ann Davey Unannounced Inspection 29th May 2007 08:30 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 Cavell Lodge DS0000015423.V337618.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. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 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.V337618.R01.S.doc Version 5.2 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. Key inspection - 11th May 2006 Random unannounced inspection – 14th November 2006 Date of last inspection Brief Description of the Service: Cavell Lodge provides care and accommodation for thirty-six older people, up to six residents may be admitted with dementia care needs. 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 summerhouse. Off road parking is available. The home is situated reasonably close to a bus route, is in a residential area, and close to local parks and woodland. The current weekly fees for residents living at Cavell Lodge range from £416.64 to £543.25. Residents pay additional costs for hairdressers, chiropody and newspapers. This information was provided on 29th May 2007. The Statement of Purpose and coloured brochure/leaflet requires updating to reflect current practice. The home does not have a Service User’s Guide. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit which started at 8.30am and finished at 6.40pm. The last key inspection took place on 11th May 2006 and a random unannounced inspection took place on 14th November 2006. Reference to the unannounced random inspection is made within this report. The acting manager, one of the registered providers, relatives, residents and staff were spoken with during the course of the day. The Commission would acknowledge that the day coincided in a 101-birthday celebration for one of the residents. A full day had been planned for the resident which included a morning celebration at coffee time, a ‘cockney’ entertainer for the afternoon and a buffet tea later. The whole home was involved in the day and the home had a constant stream of ‘well wishers’ from the resident’s friends and relatives. This made any real in-depth conversation with residents’, staff and relatives not really practicable, as the inspector did not want to impose too much on such a well-organised and personal occasion. Discussions did however take place where possible and these have been recorded in the report. Following discussion with the acting manager and registered provider, surveys were left for residents, staff, relatives and visiting professionals to complete and return to the Commission. These comments will be reflected in the next key inspection. A partial tour of the home was made. Care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection was taking place was displayed in the main entrance hallway. The notice extended an invitation to anyone who may like to speak with the inspector to make themselves known. Although it was a very busy day for reasons as described, the home was friendly, welcoming and cooperative. The acting manager was present throughout the visit and one of the registered provider’s attended for a while during the morning and returned for the final summing up early evening. All matters relating to the outcome of this inspection were discussed with the registered provider and the acting manager. Full opportunity was given for discussion/and or clarification both during and at the end of the inspection. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff recruitment records have improved, but still require development in that the home should be recording a full employment history. Care planning documentation has improved in that there is more detail, but still requires development to ensure that all aspects of care are referenced and risk assessments are current. The registered providers should undertake a more pro-active role within the home in conjunction with their regulatory obligations and undertake to be more familiar with current Commission guidance and function. The structure and function of monthly Regulation 26 visits should be reviewed so that as registered providers they can assess where the shortfalls are and put measures in place to achieve compliance. The Statement of Purpose must be updated and a Service User’s Guide devised and made available to the Commission and all interested parties. Care planning and risk assessment documentation must be improved. Medication practices must be improved in that there must appropriate storage of prescribed eye drops and liquid medication. Policies and procedures must be reviewed to ensure they are current and relative to the practice within the home. Staff recruitment process must comply with regulation. The completion of staff rotas, staff induction and staff supervision requires review. Health and safety within the home must be reviewed for the wellbeing of residents. This includes ensuring that cupboards and doors to rooms are locked which contained items that might cause harm to residents. Environmental and safe working risk assessments must be developed to ensure that residents and safe live and/or work in a safe environment. A more effective reporting process needs to be implemented to Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 7 ensure that maintenance issues are addressed. Nutritional records must be maintained in accordance with regulatory requirements. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cavell Lodge DS0000015423.V337618.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 Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 (standard 6 is not applicable in this home) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their care needs assessed by the home to ensure that the proposed placement is suitable. Information available about the home to members of the public and other professionals is not current and there is no Service User’s Guide. EVIDENCE: The records of the two most recent admissions to the home were assessed. Full assessments were in place and the assessed needs were clearly documented. Prospective residents wishes and preferences are sought and recorded. On admission, a ‘draft’ care plan is put in place. Discussion took place about the process of a current prospective placement. The relative had already visited the home and the acting manager was to visit the prospective resident in her own home. Following this, arrangements would be made for the resident to come and visit the home for the day. One resident spoken with who hadn’t been in the home for very long, spoke of her positive experience of moving into the home. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 10 The registered provider agreed that the home’s Statement of Purpose was not current and required an urgent review. The home does not have a Service User’s Guide. There is a coloured leaflet, but information on it is either outdated and/or does not comply with specific information required by regulation on a Service User’s Guide. Therefore, interested parties are not provided with current information about the home. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a plan of care but not all aspects of care and risk are recorded. The storage of prescribed eye and liquid medication is not in line with guidance. Residents can expect to receive the services of all health care professionals as appropriate. EVIDENCE: At the random inspection on 14th November 2006, it was acknowledged that the care planning processes within the home had improved and of those sampled at that time, the quality ranged for poor to adequate. At this inspection, five care plan records were assessed. The judgement from this assessment is that the quality of these too, ranged from adequate to poor. Clearly, the acting manager has worked hard in reviewing recording processes and the outcome is that documentation was in general quite orderly and clear. However, the elements of care needs are limited and do not cover all aspects of care as detailed in the national minimum standards. In the main, care plans focus on physical care needs and there is little or no reference to spiritual, Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 12 emotional and social needs for example. Some risk assessments were missing, some reviews had not taken place and ‘turning charts’ (a record of how often and when a resident is placed in a different position whilst they are in bed for a significant period of time) had not been dated. The ‘review’ of one care plan was overdue, whilst other ‘reviews’ had turned into mini care plans. It was positive to hear that the home is looking at ways to encourage residents to take an active interest in their plan(s) of care. Each resident has a ‘daily sheet’ in his or her care file. These records were informative and provided a good record of the respective resident day/night activity. The home has a ‘senior communication book’. This book is a useful communication tool for the home, but the acting manager agreed that quite detailed personal information is now being recorded in a communal book and this is not good practice. Whilst it is quite acceptable to make a brief reference to a particular matter to aid communication, it is not acceptable to record personal information in a communal format as this infringes residents’ rights of privacy of information. Care practices were observed during the day. Staff were attentive to residents needs, although it was noticed that some residents were left at the breakfast table unsupervised for some time. One resident was heard calling out for assistance and explained to the inspector that because she required assistance, she was often kept waiting at the table for some time. The acting manager needed to call staff to assist this lady. However, in general, staff were seen to be talking and assisting to residents in a dignified and friendly manner. Residents spoke of staff being kind and helpful. Relatives were also very complementary about the demeanour and caring skills of staff. Staff spoken with had a good understanding of residents assessed care needs. Residents’ health care needs are well documented and the home reported a good relationship with all health care professionals. During the inspection in November 2006, shortfalls were noted within the medication recording system. There was also an issue about the controlled drug cupboard not being fixed to a solid wall. At this inspection, medication administration records (MAR sheets) and the controlled drugs register (and tablets) were in good order. However, a selection of eye drops seen in use in the fridge, according to the instructions on the box had to be used within a 28day period, but there was no opening date recorded. There was also an open bottle of liquid medication that had to be used within 14 days of opening and stored in the refrigerator. The bottle had no opening date and was being stored at room temperature. The acting manager said that there are no PRN (as/when required) medication protocols in place and realises that there should be. Concerning the outstanding matter of the controlled cupboard, the home was given reference to the legislation about this and asked to come back to the Commission with a written outcome. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a lifestyle in the home that meets their expectations and to receive a balanced diet. EVIDENCE: Care plans need to be developed to identify and record the personal social, emotional and spiritual needs of individual residents. The home had displayed an activities programme for the current month. There were 11 organised activities/events, which included a theatre afternoon, card games, church service(s) and outside entertainers. The February programme recorded 9 organised activities such as bingo, celebrating the Chinese New Year and ‘keep fit’ and the March programme recorded 7 activities such as an outside entertainer coming in and Easter celebrations. The home has a twice-monthly church service in the home and if residents wish to attend their own place of worship, then the home will liaise with the respective church about transport. One resident attends her own church on a fairly regular basis. The home was able to demonstrate that it recognises diversity in different faiths and how needs can be met. Residents spoken with were very happy with the entertainment the home provides and clearly from the ‘cockney’ afternoon, many were quite used to a good sing. The acting manager explained that no Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 14 current residents are in bed for 24 hours a day and at some stage during the day, all spend time in the company of other residents. The home has an attractive main foyer area and clearly this is a favourite ‘meeting point’ for many residents. The home has a number of different lounges and was able to demonstrate that residents are actively encouraged to use all areas of the home, but this particular foyer area is well loved. The registered provider said that the home would be provided with its’ own transport by the end of the year. However, it was noted that residents themselves are actually raising funds for this transport. The registered provider needs to clarify if the registered providers are going to fund the transport or residents are being expected to raise the funds themselves. The situation wasn’t very clear. The home was able to demonstrate that residents are provided with a variety and choice at all mealtimes. Residents were very complimentary about food provision. However, current nutrition records were not compliant with regulation as they are not detailed and do not indicated what has actually been eaten and in what quantity. They are not being kept for the minimum of 3 years. The acting manager acknowledged this shortfall and the inspector discussed various possible recording methods for the home’s consideration. The home’s dining area is bright, attractive and full of natural light. Residents were sensitively assisted during the afternoon buffet. Cavell Lodge DS0000015423.V337618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their complaints taken seriously and to be protected from abuse by staff knowledge of safeguarding adults from harm procedures. EVIDENCE: The complaints procedure is displayed, but the content needs to be amended to reflect the current guidance sent to the home by the Commission. The home maintains a complaint record book. The acting manager spoke with confidence about the manner in which the home addresses any area of concern or complaint. Residents spoken with said that they would be happy to raise any matter of concern with the acting manager. Relatives also said that they would have no problem with approaching either the registered provider or the acting manager about a matter of concern or complaint. Records demonstrate that staff have attended ‘safeguarding adults from harm’ training. This aspect of care was discussed with a senior member of staff who said that any aspect of concern would immediately be reported to the registered provider or the acting manager. The member of staff added that the registered provider and/or the acting manager is then required to immediately contact the local authority coordinator and that the home does not investigate such matters. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is comfortable, pleasant and homely, but attention needs to be given as some specific aspects of the home to make it safer for residents. EVIDENCE: A partial tour of the home was made. Residents’ bedrooms were personalised, clean and comfortable. The communal areas of the home were bright and airy. The standard of décor and furnishings throughout the home is of a good standard. Corridors were clear from obstruction and the home has adequate storage facilities for wheelchairs and hoists. Some residents have personal telephone lines in their rooms and there is a pay telephone near the main office for residents use. There were no unpleasant in the home. There were however some shortfalls identified which must be addressed for the safety and wellbeing of residents. It was noted that many of the bedroom window opening restrictors had been removed. Whilst this would provide a Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 17 better flow of fresh air for residents, there is a potential risk of residents falling out of the 1st and 2nd floor window onto concrete paths below. There were no risk assessments in place. Within the supervised laundry area, clean clothing was seen to be in direct contact with soiled laundry. The home could not demonstrate that it had adequate infection control processes/polices in place to minimise risk of cross contamination. A meter cupboard and a room containing electrical equipment both located in areas used by residents were left unlocked. The sluice was out of order, a bathroom was out of order because the hoisting chair was faulty and the bath panels of a bath was broken and the end of the bath was secured by grey plastic tape, but parts of the tape had broken away. This area of the bath poses a potential risk to the safety of residents using this facility as the edges are loose and sharp and could cause injury to the legs of residents particularly those in wheelchairs. The acting manager said that the home doesn’t have a ‘maintenance person’ and although matters are reported to the registered provider, action can take a while. The home must look at processes whereby maintenance issues are dealt with more effectively and proactively. The acting manager said that delays can sometimes be detrimental to residents and care staff do not have the allocated hours to carry out maintenance tasks. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a team of trained staff in numbers that are adequate to meet the assessed care needs of the current residents. Records such as staff rotas, recruitment and induction are not always maintained in line with regulatory requirements. EVIDENCE: The content on staff rotas seen was clear and detailed. During the morning period there are two seniors and four care staff on duty, in the afternoon/evening there is one senior and five care staff on duty and at night there is one senior and 2 care staff to carry out ‘awake’ duties. In addition, the home employs domestic, housekeeping, cook and kitchen assistant staff to cover a 7-day period. The hours worked by the acting manager and the administrator must be recorded on the rota. The home does not provide any maintenance hours and this is something the registered providers must review. The rota continues to show that some care staff work double shifts on a regular basis. This home is again reminded that this is not good practice. Care work is physical and mentally demanding and regular long days are tiring. Whilst the home explained the reasons for this practice, it was emphasised that the home should not operate on the basis of accommodating staff preferences, but primarily it is for the safety and wellbeing of residents. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 19 The recruitment records of the two most recently recruited members of staff were viewed. Records were in good order, but the home must ensure that a detailed previous employment history is received. Those records seen were very brief and provided no employment history as required by regulation. The home has developed staff training and although records were available they were not examined as the ‘training matrix’ on the wall demonstrated this activity. The acting manager was able to demonstrate that staff supervision sessions are being developed. Care staff receive an induction, but at the moment, ancillary staff do not. The acting manager was able to demonstrate that staff meetings and senior staff meetings happen on a regular basis. Staff looked very smart and clean in their uniforms. Residents spoke well of staff and words such as ‘they’re kind’, ‘very helpful’ and ‘they’re lovely’ were expressed. Relatives were also complimentary about the staffing group. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered person through the Regulation 26 process needs to review local management practices to ensure that current and future practice within the home is compliant with regulation. EVIDENCE: At the last key inspection in May 2006, it was reported that the newly appointed acting manager was in the process of completing her application for the position of registered manager. This hasn’t happened and the home remains without a registered manager. Assurances were given that a full application is now imminent. The acting manager does not have a job description and will need a specific area(s) of responsibility profile for her application of registered manager. Currently there is a blurred strategy about areas of responsibility and accountability. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 21 The last key inspection report recorded significant shortfalls in the home and as a result a further unannounced inspection was undertaken in November 2006. Whilst some improvements were noted at the second visit, shortfalls still remained. Following the May 2006 inspection, the registered provider wrote to the Commission expressing surprise about the content of the report and said that he was ‘confident things at Cavell Lodge will soon be in excellent shape’. A report was sent to the registered provider following the visit in November 2006 identifying shortfalls, but no further response was received. The Care Homes Regulations require a registered provider to undertake a Regulation 26 visit (registered provider to visit the home at least once a month and prepare report of the findings). Regulation clearly sets what should be undertaken during these visits. This process through a regulatory function provides the registered provider an opportunity to form a judgement about the way the home is conducting itself and as a result, regulatory shortfalls can be identified and addressed through a regular review process. It is the responsibility of the registered person(s) to ensure that a registered home meets regulatory requirements. Since November 2006, the registered provider has undertaken four such Regulation 26 visits. The records of those visits do not demonstrate that the registered provider has undertaken a full review of the home since their last inspection visit, neither have the visits been undertaken in accordance with regulation. For example, there was no evidence that policies and procedures are reviewed, the Statement of Purpose is kept up to date, or ensuring that a Service User’s Guide is available for residents. There is no evidence that the acting manager receives formal supervision or is involved in the Regulation 26 visits and there is also no evidence that a systematic review of the shortfalls identified within the last two inspections undertaken by the Commission has taken place and a plan to address formulated. From discussion with one of the registered providers during this inspection, it was clear that there is some misunderstanding about the Commission’s function and there was little evidence that there was is clear understanding of current CSCI guidance sent to homes in the past year via newsletters and letters. It was evident that the acting manager is competent, skilled, able to demonstrate sound care values and has raised standards within the home. The acting manager is committed and dedicated to her work and demonstrates sound management values. In the past year, she has undertaken a considerable staff development programme and has earned respect from staff and other visiting professionals. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 22 Policies, procedures, documentation and current practices must be reviewed by the registered providers to ensure that the home is compliant with regulatory requirements and the national minimum standards. To support the acting manager with the development of care practice documentation, care practices and staff development, she requires support and input from the registered providers. A clear process should be evident in how compliance is going to be reviewed and maintained by the registered providers. It is not satisfactory for the home to wait until the manager is registered. There must be pro-active intervention and support from the registered providers. Accident records were seen and maintained in good order. An accident that had occurred the night before the inspection had been properly recorded and the resident concerned said that staff had managed the incident well. A random selection of service and maintenance records were sampled and found to be in good order. The home employs the services of an external company to check the function of fire alarms, emergency lighting, call bells and fire fighting equipment. These checks are carried quarterly. The home was asked to ensure that the regularity of these checks was satisfactory in terms of risk, as no other ‘in house’ checks are undertaken. There were no risk assessments in place concerning this matter. The acting manager said that a maintenance person should undertake ‘in house’ checks, but the home didn’t employ such a person. This was discussed with the registered provider who said that he acknowledges the risk factor, but thought that current arrangements were satisfactory. The acting manager said that the home does not have any current safe working/environment risk assessments. Advice was given about this. The home safe keeps personal allowances for some residents. A random selection of records and monies were viewed. These were in good order. The home was able to demonstrate that the views and opinions of residents are actively sought through regular resident/relative meetings. Records demonstrated that a variety of aspects are discussed during these meetings. The home acknowledges that the Quality Assurance system needs to be developed. The home was going to use the surveys sent to residents by the Commission as part of this process. The acting manager was reminded that residents have a right to send back their completed surveys in the SAE to the Commission anonymously and without any involvement from the home. The home demonstrated an openness about the value it holds about residents’ thoughts, opinions and ideas. Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X 2 2 Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4,5 & 6 Requirement The home must have a Statement of Purpose and Service User’s Guide which reflects current practice and is made available and/or given to all in interested parties. The content of both documents must comply with regulatory requirements. Both documents must be kept under review. When completed, both documents must be sent to the Commission. Without these documents, residents, relatives and all interested parties will not have current information about the home. 2 OP7 15 Every resident must have a detailed current plan of care in place. This document must include all aspects of care/health as detailed in the minimum care standards (No 3), contain appropriate risk assessments and demonstrate that residents have been consulted about choice and preferences. DS0000015423.V337618.R01.S.doc Timescale for action 15/08/07 31/07/07 Cavell Lodge Version 5.2 Page 25 These documents must be kept under regular review and be made available to the respective resident and/or their representative. Without adequate documentation, staff may not be aware of assessed care/health needs or how they should be met. The previous two timescales of 1/8/06 and 1/2/07 to meet this requirement have not been achieved in full. 3 OP9 13 Current medication practices must be reviewed to ensure that all practices are in line with legislation and guidance for the safety and wellbeing of residents. Details of the presenting shortfalls are within the report. This was mainly in respect of poor practices concerning the maintenance and storage of eye medication, liquid preparations and the lack of PRN (as/when) medication administration protocols. The previous two timescales of 1/7/06 and 1/1/07 to meet this requirement have not been achieved in full. 4 OP15 16 & 17 The home must maintain a form of record to demonstrate that residents are provided with food and drink (fluids) which are in adequate quantities, suitable, wholesome, nutritious and varied. These records must be kept for a period of 3 years in accordance with regulatory requirements. DS0000015423.V337618.R01.S.doc 30/06/07 30/06/07 Cavell Lodge Version 5.2 Page 26 5 OP19 OP25 OP26 12,13 & 16 For the safety and wellbeing of residents there must be a clear process by which routine maintenance matters are dealt with, adequate infection control measures are in place, cupboards housing electrical equipment is kept locked, adequate measures are taken to prevent residents falling out of windows and a review of the way fire alarms, fire fighting equipment and emergency lighting are check to ensure that they are in good working order. The home must maintain a staff rota that shows all staff on duty. This includes management and administration staff. For the wellbeing and protection of residents, the home must maintain staff recruitment records as required by regulation. This includes obtaining a full employment history. Also, all staff (including ancillary staff) must receive structured induction training. The previous two timescales of 1/8/06 and 31/12/06 to meet this requirement(s) have not been achieved in full. 30/06/07 6 OP27 17 30/06/07 7 OP29 18 & 19 30/06/07 8 OP37 4,12,13, 14,15,16 17,23,24 & 26 30/06/07 The registered persons(s) must review all policies, procedures and guidance within home to ensure that they are current and that staff know about them. There must be a process by which the home can demonstrate that this documentation is reviewed. For the best interests of residents and staff, this process must start immediately. DS0000015423.V337618.R01.S.doc Version 5.2 Page 27 Cavell Lodge In addition, the registered provider must undertake Regulation 26 visits in accordance with regulation. 9 OP38 13 For the safety and protection of staff and residents environmental and safe working place risk assessment must be devised and put in place. They must be reviewed periodically to ensure that they are current. 31/07/07 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 OP10 OP16 Good Practice Recommendations Work practice routines after the breakfast period should be review to ensure that the dignity of residents is maintained and that they do not have to call out for assistance. The complaints procedure should be reviewed and amended to reflect current Commission guidance, which states that complaints should be investigated in accordance with the homes procedure. The Commission does not have a regulatory function to investigate complaints. All staff should receive supervision sessions so that professional practice can be monitored and any training gaps identified. A registered manager’s application should be made as soon as possible. This will provide the home with a stable local management structure. 3 4 OP29 OP31 Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cavell Lodge DS0000015423.V337618.R01.S.doc Version 5.2 Page 29 - 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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