Inspection on 30/10/07 for Cavell Lodge

This inspection was carried out on 30th October 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 29/05/07

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 30th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cavell Lodge DS0000015423.V349891.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.V349891.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 cavelllodge@btconnect,com 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.V349891.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. 29th May 2007 Date of last inspection Brief Description of the Service: Cavell Lodge provides care and accommodation for thirty-six older people, some may be admitted with care needs associated with dementia. The home particularly caters for residents with medium to low dependency needs. The home is purpose built and provides a good 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, to local parks and a woodland area. The current weekly fees for residents living at Cavell Lodge range from £428.00 to £543.25. Residents pay additional costs for hairdressers, chiropody and newspapers. An amended Statement of Purpose and Service User’s Guide is in final draft and will be ready by the end of the year. The home has a coloured brochure/leaflet that has been updated and reflects current practice. Cavell Lodge DS0000015423.V349891.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 that started at 9.30am and finished at 5.30pm. The last key inspection took place on 29th May 2007. Following that inspection, the Commission requested an Improvement Plan from the registered providers. Information about what has improved in the home and what remains outstanding is detailed below and referenced throughout the body of the report. The home had completed and returned their Annual Quality Assurance Assessment (AQAA) to the Commission prior to the inspection. This document gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as future plans for improving the service. The registered provider, manager, residents, staff and visitors were spoken with during the inspection. The Commission received six completed surveys from staff, ten completed surveys from residents and 4 completed surveys from relatives. Comments from these surveys were generally very positive and have been incorporated within the report. The day was pleasant and the home cooperative and helpful. The inspection was undertaken with ease. The home has not had a registered manager for nearly two years. The current person in charge of the day-to-day management of the home has been in post for approximately eighteen months. A partial tour of the home took place. 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. All matters relating to the outcome of this inspection were discussed with the manager and the registered provider. The manager took notes so that development work could be started. Full opportunity was given for discussion and/or clarification both during and at the end of the inspection. What the service does well: The home is bright and airy and the standard of furnishing and décor is good. This makes the home a very pleasant environment for residents to live in. The atmosphere in the home is warm and homely. Resident’s views and opinions are actively sought and valued. The home makes visitors very welcome and there is a comfortable private room available if required. Staff are friendly. Residents have a good choice of food that can be served in the pleasant dining area or in the privacy of their own rooms if preferred. The home’s admission process is robust. Residents can be assured that their needs will be fully Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 6 assessed before they are admitted. The home provides and/or facilitates a wide and varied range of activities that in the main meets the needs of residents. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (standard 6 is not applicable in this home) 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 receive current information about the home and to have a comprehensive pre admission assessment carried out to ensure their identified needs are met. EVIDENCE: The record of the most recently admitted resident was seen. A detailed ‘pre admission assessment’ and also an ‘on admission assessment’ had taken place. An interim care plan reflecting the assessed needs had been put in place. The home’s amended Statement of Purpose and Service User’s Guide is in final draft and will be ready for distribution by the end of the year. The home’s coloured brochure has been updated and is available from the home. Information within completed surveys received from residents and relatives, indicated that information about the home was readily available. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 9 Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot be assured that care plans will always reflect their assessed care needs or their specific medication administration requirements are recorded. EVIDENCE: Three care plan records and other associated care/heath documentation were selected at random and assessed. Records included risk assessments, daily notes and health care professional visits. One set of records was in good order, but the other two did not meet regulatory requirements. One resident had been discharged from hospital two weeks previous and although a further assessment had been carried out by the home which identified needs, the care plan had not been updated and therefore did not reflect current needs. The third set of records only covered three aspects of care i.e. medication, social needs and assistance with Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 11 bathing/dressing. There was no reference within documentation about other care needs. Without current and up to date information, care staff may not know the individual care needs of residents and/or how to meet them. Also in the event of a resident requiring the assistance of emergency medical or clinical intervention, the information available to them may not be accurate or current. This is the third inspection when this shortfall has been identified. The home said that staff have received ‘care plan documentation’ training and ‘stickers’ within various pages of the documentation demonstrates that the manager is monitoring the situation and identifying ‘gaps’ in the system. However, it is of concern that following repeated assurances from the home that this shortfall will be addressed, regulatory requirements are still not being met. The home maintains a ‘senior communication book’, which can be a useful communication tool. However, as on the previous inspection, personal information relating to individual residents had been recorded in this communal book. This practice remains unacceptable as it infringes residents’ rights of privacy of information. Residents’ health care needs were adequately recorded in those records seen. The home reported a good working relationship with health care professionals. Residents’ are registered with one of the four local group practices. The Community nursing service visits the home on a regular basis to carry out required nursing practices i.e. dressings, insulin injections. Good care practices were observed during the course of the day. Staff were attentive to residents needs and had a good understanding of individual residents needs. Residents spoke positively about the ‘kindness’ of staff in the home. The completed surveys responses from residents and relatives were mainly ‘tick box’ i.e. yes/no/sometimes, but there were no negative comments made about care practices. During the afternoon, a resident in one of the lounges was experiencing some difficulty. The inspector noticed this and activated the call bell. Staff were not aware of the inspectors location and it was reassuring to note that a member of staff came to answer the call bell quickly. The member of staff dealt with the situation in a sensitive manner. Residents were clothed in keeping with their age and gender. The atmosphere within the home was calm, homely and warm. The home provides care for residents with specific needs associated with dementia. Around the home there were boxes of latex gloves and plastic bags left unsupervised in corridors and bathrooms. The manager agreed that this practice poses a potential risk to some residents and said they would immediately address the situation. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 12 At the previous two inspections, regulatory shortfalls were identified with the medication storage and administration recording system. It was positive to note that all shortfalls except for one, has been addressed. The shortfall remaining is regarding PRN (as/when required) medication administration instruction protocols not being in place. Cavell Lodge DS0000015423.V349891.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 and 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 be provided with a varied programme of social activities/events and to receive a balanced diet. Residents cannot be assured that a record of their diet will be recorded. EVIDENCE: Information on some care plans still need to be developed to fully identify and record individual residents preferences concerning social and occupational activities. The corporate October social activity programme which was displayed was varied and contained no less than 15 varied structured activities i.e. Pearly Queen show, musical afternoon event, residents meeting and twice monthly church services. During the year, residents are actively involved in arranging their own raffles and fetes. During the summer months the home hired a minibus and residents enjoyed a number of days out. During the inspection in May 2007, the registered provider said that by the end of this year the home will have it’s own minibus. During the morning of the inspection, residents were appropriately occupied either in their own bedrooms, in the foyer/lounge area at the front of the home Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 14 or the lounge area. During the afternoon, approximately ten residents were enjoying a relaxed card game with a member of staff whilst having their afternoon tea in the dining area. Comments from the completed surveys were positive about the range of social activities and events the home facilitates. Several comments were received suggesting that the home should review the range of activities to ensure the inclusion of those who have care needs associated with dementia. When given this ‘feedback’, the home acknowledged that this was something that should be developing especially in the area of day trips. The home was able to demonstrate that some residents are taken out by staff on a 1:1 basis when time and resources permit. The home has a comfortable designated private ‘visitors room’. During the course of the day there was a steady stream of visitors. Those spoken intimated that visiting Cavell Lodge was a positive and pleasurable experience. Staff were seen to be engaging with relatives in a friendly warm manner. Information obtained from the completed surveys was very positive about food provision. The lunch and teatime menu for the day provided a good choice. Residents spoken with were completely satisfied with meals in the home. Tables had been attractively laid for lunch and from a brief glimpse, the food served was well presented and looked appetising. The dining room that overlooks the well-laid rear garden area was bright and airy. At the last inspection, it was noted that the home was not maintaining nutritional records in accordance with regulatory requirements. The home assured that this matter would be addressed. At this inspection, the home was not able to demonstrate that this shortfall has been addressed. The home was able to demonstrate that a recording format has been devised, but the system has not been implemented. Cavell Lodge DS0000015423.V349891.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 and 17 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 reporting procedures. EVIDENCE: Information within the completed surveys indicated that all those surveyed (residents and relatives) knew how to raise a matter of concern or complaint with the home. The complaints procedure was displayed and the home has an established complaints recording system. The home manager spoke of the competent way in which they had recently managed a complex concern. Residents spoken with during on the day said that they would be happy to raise any matter of concern with the manager. Records stated 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 raised would immediately be reported to the registered provider or the manager who is then required to immediately contact the designated and named local authority coordinator. It was understood that the home does not investigate such matters ‘in house’. The manager demonstrated a good understanding of ‘safeguarding adults’ matters. Cavell Lodge DS0000015423.V349891.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 and 26 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 live in a comfortable, pleasant and homely environment. EVIDENCE: A partial tour of the home was made. Residents’ bedrooms were personalised, clean and comfortable. Communal areas were bright and airy. The standard of décor and furnishings is of a good standard. Corridors were clear from obstruction. Wheelchairs and hoists were stored away from the main walkways. Some residents have personal telephone lines in their bedrooms and there is a pay telephone near the main office on the ground floor for residents use. There were no unpleasant odours in the home. The rear garden area is very pleasant with a lawn, flowerbeds and a patio area. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 17 Residents and relatives in their completed surveys spoke positively about the environment. Two surveys from relatives suggested that perhaps the home could consider a better style of ‘easy’ chair for the less mobile in lounge areas and one survey suggested that a rail in the main corridor might be helpful for residents. The home received these comments well and said that they would certainly take on board what had been said. On the day, two residents who choose to spent time in their rooms were spoken with. Both said that they enjoyed the privacy of their bedrooms and felt ‘at home’ and of ‘being comfortable’. Other residents spoken with in the communal areas looked comfortable and relaxed. It was positive to note that the environmental shortfalls identified at the last inspection have been addressed. For example, functional window opening restrictors on 1st and 2nd floor bedrooms windows are now in place and infection control/cross contamination processes have improved in the laundry area. Cupboards and rooms housing electrical equipment is now secured and the broken baths panels and/or lifting hoists have either been repaired or new equipment has been ordered. In addition, the home now employs a ‘maintenance man’ for eight hours a week. This ensures that routine maintenance tasks are carried out on a regular basis. The manager said that this has been a great asset to the home. Cavell Lodge DS0000015423.V349891.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 and 30 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 be cared for by a team of trained and robustly recruited staff on each shift. EVIDENCE: The staff rota for the current week was clear, detail and accurate. In the mornings two seniors and four care staff are on duty. In the afternoon/evening there is one senior and four care staff on duty and at night there is one senior and two care staff to carry out ‘awake’ duties. In addition, the home employs administration, maintenance, domestic, housekeeping, cooking and kitchen assistant staff. The manager said that staff turnover is minimal and residents’ benefit from being cared for by a core team of established staff. Agency staff is only used to fill holiday or sick leave periods. Some staff continue to work regular ‘double shifts’ i.e. 13-hour days. The manager said that staff prefer to do this, although the home accepts that this is not good practice because of the physical and mental demands of the job. It was positive to note that staff recruitment files seen now contain a detailed and informative ‘employment history’ as required by regulation. The home has a clear and detailed ‘training matrix’ displayed demonstrating that staff training is monitored and provided. A discussion took place whereby the home Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 19 acknowledged that although staff training had taken place, the home should consider a process whereby the competency of staff following training is also assessed. Particular mention was made that although staff have received training on care plan recording, medication administration recording and nutrition recording, the content of these records did not comply with regulatory requirements. The home has established staff induction and staff supervision processes in place. Records demonstrated that regular staff meetings take place. Comments from staff surveys said that they felt supported, receive adequate training, were able to raise any concerns and had sufficient information to do their jobs. Staff felt that there were sufficient numbers of staff on each shift to provide good care and confirmed that agency staff are only used in the event of holidays or sick leave. Residents within their surveys were positive about staff in the home. They felt that staff listened to them and were always available. Relatives within their surveys felt that staff had the right skills to provide the care required. Cavell Lodge DS0000015423.V349891.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 and 38 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 live in a home where the day-to-day management processes continue to be developed which will have a positive impact of the quality of care provided. EVIDENCE: During the inspection on May 2006, the manager said that the application for the position of registered manager would be submitted. At the inspection in May 2007, the application remained outstanding. At this inspection the application was still outstanding. A frank discussion took place about the delay. The manager feels that the home has made good progress and is now happy to make the application. It is important that the manager is provided with a clear job description as currently lines of responsibility and accountability are Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 21 blurred. This matter was referred to at the last inspection. The manager now attends various local ‘providers/ managers meeting’ and has found them to be very useful and informative. The registered providers should also try to attend. Management should review the staff supervision and staff competency processes within the home. Staff are being trained, but shortfalls identified with the care planning, medication and nutritional recording systems would suggest that more effective management monitoring is required. The manager has demonstrated skill and competence in raising standards in the home over the past 12 months. The manager hopes to complete the NVQ level 4 in Care Management in the New Year and to enrol on a Registered Manager’s Award course as soon as a place becomes available. Staff made some very positive comments about management within their surveys. All thought that the manager was supportive and approachable. Since the last inspection, the home has made some good progress on the dayto-day management systems within the home. For example, the registered provider(s) are more proactive and regularly complete their statutory Regulation 26 visit/report, an external consultant/company has been actively involved in updating environmental/fire risk assessments and the policies/procedures for the home. This work is due for completion by the end of the year. The registered provider and the manager understands that once this huge piece of work has been finalised, management will need to agree on how to delegate, implement and monitor matters. Some recommendations from the various consultancy reports have already been carried out i.e. fire risk assessments. The appointment of a ‘maintenance man’ means that the management of regular and routine maintenance issues i.e. checking fire alarms, emergency lighting, replacing bulbs has improved significantly. On the day of the inspection, routine maintenance work was in progress. By coincidence, the fire alarm was accidentally triggered off and it was positive to note that all fire doors closed properly and staff followed the fire procedure by making their way to the designated fire assembly point. The home safe keeps personal allowances for residents on request. A random selection of records and monies were viewed. These were in good order. The views and opinions of residents, staff and relatives are sought through regular and established well-documented meetings. Accident records were seen and maintained in good order. The home has started work on a Quality Assurance system by preparing some detailed surveys for distribution and intends to fully develop the system by the next inspection. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 22 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 3 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 3 X X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 23 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 OP7 OP37 Regulation 15 Requirement 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), and contain appropriate risk assessments to demonstrate that residents have been consulted about choice and preferences. 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 three timescales of 1/8/06, 1/2/07 and 31/7/07 to meet this requirement have not been achieved in full. Timescale for action 31/12/07 Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 24 2 OP9 OP37 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 in respect of the lack of PRN (as/when) medication administration instruction protocols. The previous two timescales of 1/7/06 and 1/1/07 to meet this requirement have not been achieved in full. 31/12/07 3 OP15 OP37 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. The previous timescale to meet this requirement of 30/06/07 has not been achieved. 31/12/07 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 Refer to Standard OP31 Good Practice Recommendations A registered manager’s application should be made as soon as possible. This will provide the home with a stable local management structure. Cavell Lodge DS0000015423.V349891.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V349891.R01.S.doc Version 5.2 Page 26 - 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!