Inspection on 19/10/06 for Cavendish Lodge

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish Lodge 16/01/09

Cavendish Lodge 21/01/08

Cavendish Lodge 01/03/06

Cavendish Lodge 05/05/05

Cavendish Lodge 13/12/04

Cavendish Lodge 05/05/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Cavendish Lodge 41 Leam Terrace Leamington Spa Warwickshire CV31 1BQ Lead Inspector Catherine Mundy Key Unannounced Inspection 19th October 2006 09:30 Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 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 Cavendish Lodge DS0000004390.V306493.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 Adults 18-65. 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. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish Lodge Address 41 Leam Terrace Leamington Spa Warwickshire CV31 1BQ 01926 427584 01926 427584 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) www.rethink.org Rethink Dawn Bicknell Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Cavendish Lodge is a nursing home for eight people with mental health problems, which is part of the Rethink Organisation (formerly NSF). The Home is situated within walking distance of the town centre and local parks. The home aims to provide a supportive residence in which eight people with enduring mental health problems can have a sense of belonging, be treated with respect and exercise choice in their daily lives. Each individual is encouraged to participate in activities suited to their own needs and wishes, to access local resources and facilities and to manage social and familial relationships beyond the home. Through the long term development of trust between service users and staff, the fostering of hope and focus upon strengths, the home endeavours to enable people to approach their potential and to achieve some recovery in the quality of their lives. The current weekly charge is £411.19, this information was provided by the manager on 21st April 2006. Additional charges are made for some items. Information relating to these charges has not been provided to the Commission. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, it took place on 19th October 2006 at 9.30 am. The inspection included a tour of the home, discussions with the staff and service users, observations of the interactions between the service users and the staff, records relating to the service users and the management of the home were examined. The manager was not present during the inspection. In addition to this the home has completed a pre inspection questionnaire. Comment cards have been completed by six of the service users. Comment cards were not received from the service users relatives/representatives. What the service does well: Throughout the inspection the service users were supported in a sensitive and dignified way, it is clear that positive relationships have been formed between the service users and staff. The service users were relaxed and comfortable within the home. They said that they like living in the home and feel well cared for. Comments made by the service users during the inspection and in their comment cards include “it’s a good place to live”, “I like everything about the home” ,“I feel safe”, “the staff treat me well” and “the staff listen to me if I have a problem”. The service users are supported to make decisions about their every day lives. Where necessary the staff support the service users with this. They are actively involved in the development of their own care plans, and take part in activities around the home that assist them to maintain and develop their independence. These include house hold chores, laundry and preparation of meals and drinks. The service users continue to receive support from other health care professionals, and access the local GP surgery for routine health screening. The home has a planned menu that is rotated every two weeks. The service users preferences are taken into account when deciding on the menu. Service users said that they liked the food that is provided and confirmed that they are offered an alternative meal if they wish. The service users said that they are able to participate in a range of activities that they enjoy. This includes college courses, shopping, going to pubs and cafes and going to a disco each month. The service users have also recently been on holiday to Skegness, which they said that they enjoyed. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 6 Service users continue to be able maintain relationships with family and friends. One service user said that his visitors could come to the home at any time. The service users spoken with confirmed that they know how to complain and are confident that any issues raised will be addressed by the staff. What has improved since the last inspection? What they could do better: The home has reduced staffing ratios at key times of the day. This has had a negative impact upon the service that is provided in the home. The organisations representative has stated that this is a pilot and staffing ratios will be reviewed in mid December 2006. The organisation has completed a risk assessment and identified strategies to reduce any risks identified with this reduction. Not all of the strategies are in place. The risk assessment states that the staff that work in the home on their own will complete training in fire safety, lone working and de-escalation of challenging situations. Not all of the staff have had this training. Although the service users each have a plan of care that details the support that is required to meet their current needs. These plans do not always take into account the service users long term goals and aspirations. The plans do not reflect the changes to the ways in which staff support is now provided. The service users do not always have a choice about whether they are supported by a male of female member of staff. There are some occasions when the planned staffing rota has only male or female carers on duty. The service users care plans do not indicate what arrangements are in place when intimate personal care is to be provided by a staff member of the opposite sex. A nurse administers the service users medication. The records relating to this state that the medication is administered ‘morning’, ‘noon’, ‘teatime’ and ‘bedtime’. The actual time of administration is not recorded. On the day of the inspection the medication was given to the service users from 10 am. The service users are at risk if there is not sufficient gap between their doses. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 7 One service user who chooses to self-medicate. This service user does not have a secure place to store her medication. Although the service users are able to participate in a range of activities during the day and in the evenings, opportunities for this will be reduced due to the reduction in staffing ratios. On the day of the inspection one service user went shopping to purchase some items of clothing. A staff member who was not on duty supported this activity. The service users have a weekly meeting. During this meeting the service users choose the activities that they would like to do that week. The service users are not always able to take part in the activities that they have chosen. The home must make sure that the dishwasher is replaced and the broken dishwasher and washing machine are removed from the home. There is a leak in one of the bathrooms and the seal has broken on the floor. In another bathroom the blind is broken and has been taken down. The home must address this. The home must also make sure that the service users can lock their bedroom doors if they wish. Two service users have difficulty when locking and unlocking their bedroom doors. The staff have a spare key to the bedroom doors, but they would find it difficult to get into these bedrooms quickly if there was an emergency. The home must also ensure that the fire safety risk assessment is completed and that fire safety equipment is regularly serviced. 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. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: The standards within this section have been met at previous inspections. There have been no changes to the service users residing in the home since that time. These standards were therefore not assessed on this occasion. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the service users have a detailed plan of care that reflects their current needs and wishes; changes made to the staffing ratios limits the homes ability to implement these plans. The service users cannot be confident that they will receive the support that they need to achieve their long term goals. EVIDENCE: A sample of service users files were examined. These contained sufficient information to demonstrate that the service users have an up to date plan of care that details how their assessed needs are to be met. Risk assessments have been completed and risk management strategies devised where these are appropriate. There is evidence that the service users are involved in developing their care plans and are consulted when these plans are reviewed. Any limitations that are in place are agreed with the service users and reflect the risks that have been identified. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 11 Discussions with the staff, service users and observations during the inspection indicate that changes to the staffing ratios at key periods of the day will have a negative impact upon the homes ability to implement the care plans that are in place. For example some service users require staff support to attend to their personal care needs such as assistance with bathing and incontinence. Discussions with the staff confirm that service users will not be supported with this at times of the day when there is one staff member on duty. (Please also refer to the staffing section of this report.) The philosophy of the organisation focuses upon ‘recovery’. Each of the service users has a recovery plan in place. This details the service users long term goals and the strategies in place to assist the service users to achieve these. In two of the files examined these documents were incomplete and for one service user the document was blank. Discussions with the service users and examination of their files and other records confirm that the service users are supported to make decisions that affect their every day lives. Observations during the inspection and discussions with staff confirm that service users are supported with this in a way that promotes their independence and gives them control over their lives. The staff and service users confirmed that the decisions made by the service users are respected by the home. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home supports the service users to access a range of activities that promote their independence, provide opportunity for personal development and that they enjoy; The service users can not be certain that the choices that they make will be facilitated. The service users continue to be supported to maintain relationships with their family and friends. They are provided with a varied diet, that reflects their personal preferences and that they enjoy. EVIDENCE: Discussions with the service users and observations during the inspection confirmed that the service users are able to participate in a range of activities that promote their independence and that they enjoy. On the day of the inspection service users were observed to participate in house hold chores, some service users went to the local shops independently, others spent their time relaxing in the home. One service user was looking forward to going Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 13 shopping for items of clothing. The staff said that a staff member had come into work on their day off to facilitate this trip. The service users said that they also have opportunities to go to the local pubs and cafes and go to a disco once a month. Other activities include college courses, which the service users said that they enjoy. The service users and staff said that the service users preferences relating to the activities planned for each week are sought on Mondays at the weekly house meetings, the staff said that a meeting had not taken place in the week of the inspection. Examination of the records relating to these meetings demonstrated that choices are made. There is little evidence in these records to confirm that the activities chosen are provided. Discussions with the staff and service users indicated that it is believed that the opportunities to participate in activities both at home and in the community would be reduced as a result of a reduction of staffing ratios in the evenings. (Please also refer to the staffing section of this report.) Discussions with the service users and staff confirmed that the service users are able to have visitors; the service users confirmed that their relatives are invited to social events. One service user commented that his visitors could come to the home at any time. Some of the service users choose to lock their bedroom doors; All of the service users comment cards stated that they are able to keep their things private. The staff were observed to knock on bedroom and bathroom doors before entering. Discussions with the service users and observations during the inspection confirmed that the service users have opportunity to develop their independence. Each service user has a timetable of chores, which include tasks such as washing up, hoovering, dusting and laundry. The service users are able to prepare their own meals if they wish. The service users were observed to choose and prepare their own breakfast and some service users are supported to prepare their own evening meals. This is on a rotational basis, although one service user is able to prepare her meal more frequently. Some areas of the kitchen are locked to promote the safety of the service users and staff. This did not have affect the service users access to drinks and snacks. The service users were able to make drinks when they wished. Discussions with the service users confirmed that they enjoy the meals that are provided. It is indicated in 3 service users comment cards that they do not have a choice of meals. However examination of the planned menu confirmed that the service users have a varied diet that reflects the service users Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 14 preferences. The staff member confirmed that the service users are provided with an alternative meal if this is requested. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Changes made to the staffing ratios and the way in which staffing is planned restricts the service users opportunities to receive personal and health care in a way that they prefer and require. EVIDENCE: During the inspection the staff were observed to support the service users in a sensitive way that promotes their privacy and dignity. The service users said during the inspection and in their comment cards that they feel safe in the home and are treated well by the staff. The level of support required to assist the service users to attend to their personal care needs is recorded in individual care plans. These are agreed with the individual service user. As noted earlier in this report the care plans have not been updated to demonstrate how the service users personal care needs are met in view of the reductions in staffing ratios. (Please refer to the staffing section of this report.) Discussions during the inspection confirmed that the service users do not always have a choice as to whether they are supported by a male or female staff member. Examination of the staffing rota provided at the time of the Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 16 inspection indicates that there are occasions when the home is staffed entirely by carers of the same sex. The care plans examined did not include a risk assessment relating to the need for staff members to be chaperoned when supporting a service user with personal or intimate care. The care plans examined confirmed that the service users health needs continue to be met appropriately by the home, this is with the support of the relevant health care professional. The home also supports routine health screening, at appropriate intervals. Records are retained of all contacts with a health care professional and of the outcome for the service user. The staff stated that physical restraint is not used in the home, they confirmed that training relating to de-escalation of challenging situations and breakaway techniques has been provided. Of the staff on duty during the inspection one staff member said that they she had not yet received this training and the other stated that he was due to have a refresher of this training. The nursing staff retain responsibility for ordering, storage, administration and disposal of medications for the majority of service users. These medications are stored securely, and records maintained of medication administration. Records are also maintained of any medications that are received by the home and those that are disposed of. Observations during the inspection confirmed that the staff began to administer the service users morning medication when the second staff member came on duty at 10am. The staff confirmed that prior to the staff changes the service users received their medication on rising. Medication is also administered at noon, teatime and bedtime. The staff confirmed that medication is usually administered at 12 noon, 5pm and 10pm. The medication administration records do not state the exact times for medications to be administered. One service user self medicates. This service user is given a weeks supply of her medication. Discussions with this service user confirmed that she understands when and how to take this medication and of the implications of not taking the medication. The medication is not stored securely, the service user chooses to keep the medication in her bedroom, but she does not have a lockable space to keep the medication secure. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are confident that any complaints made or concerns raised will be listened to and acted upon. EVIDENCE: The service users spoken with confirmed that they were aware of the complaints procedure and were confident that the staff would listen to and act upon any complaints that they made. The service users stated that they are happy with the service that is provided. One service user stated in their comment card that they were not aware of the complaints procedure. A copy of this procedure is displayed in the hallway of the home. Discussions with the staff confirmed that in the event of a complaint or an allegation of abuse being made appropriate action would be taken. Information provided in the pre inspection questionnaire confirmed that the home has not received any complaints since the last inspection. The Commission for Social Care Inspection has also not received any complaints in relation to this service. The organisation has demonstrated in information received separately to this inspection that appropriate procedures are in place to protect the service users from abuse. Although one staff member spoken with during the inspection confirmed that she has not received training with regard to adult protection. The service users monies are held securely by the home. Access to this is restricted to nominated employees. Confirmation that these are handled Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 18 appropriately could not assessed on this occasion, as the manager was not present during the inspection. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality in this outcome area is adequate .This judgement has been made using available evidence including a visit to this service. The standard of the environment is generally good, this would be improved when the shortfalls identified are addressed. EVIDENCE: This inspection included a tour of some parts of the home, including all of the communal areas and four service users bedrooms. There are two lounges on the ground floor, one of which can be used when the service users wish to smoke. The dining table is located in the other lounge. Both were attractively decorated. The home also has a large kitchen which the service users can access when they wish although some cupboards are locked. Each of the service users have their own bedrooms. The bedrooms seen were furnished and decorated to reflect the service users individual preferences and personalities. One service user confirmed that he was bale to choose the colour of his décor. Some service users have ensuite bathrooms which consist of a shower, toilet and sink. Where these are not provided the service users have a wash hand basin. In addition there are two communal bathrooms, one with a ‘parker’ bath that has a spa function. Both bathrooms have an emergency call Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 20 button. The service users confirmed that they know how to summon assistance if need be. There is also an additional W.C. A requirement made at the last inspection to improve the décor and cleanliness of some parts of the home has been met. The hallways and smoking room have been redecorated by the staff. The service users confirmed that they were consulted on the colour scheme. A requirement made to replace the carpet in the hallway has not been met. During this inspection it was noted that the homes dishwasher and Urn were broken, and an old washing machine was stored in the hallway. The seal on the ground floor bathroom was damaged and there is evidence of water damage where pipes have been ‘boxed in’ .The blind in the first floor bathroom is broken. During this inspection it was evident that the locks on two service users bedroom doors were damaged. The service users and staff had difficulty in locking and unlocking these doors. Discussions with the service users and staff and observations during the inspection confirmed that the home has appropriate procedures in place to reduce the risk of cross infection. Hand washing facilities are available in the kitchen and laundry and appropriate cleaning materials and equipment were available. On the day of the inspection the home was clean and tidy. The laundry facilities are appropriate for the needs of the home. They consist of a washing machine, which has a facility to wash items at high temperatures if required and a tumble dryer. The service users maintain responsibility for laundering their own clothing and linen. This is done on a rotational basis. Staff support is provided if required. This was observed during the inspection. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Changes to the way in which the home is managed affects the effectiveness of the staff team to best meet the service users needs. EVIDENCE: The staffing ratios within the home have been reduced. This is at key times of the day. There is one staff member on duty between 8am and 10pm and between 6pm and 9pm. This change had been made on 16th October 2006. Previously there had been a minimum of two staff on duty at all times. Discussions with the organisations representative following this inspection confirmed that the reductions in staffing ratios are part of a pilot. The organisations representative stated that the service users and their carers had been consulted about the planned changes. She stated that the staffing ratios will be reviewed in December 2006 before permanent changes are made. The organisation has provided guidance to staff, completed a risk assessment and identified strategies to reduce the risks identified. Discussions with staff and observations during this inspection confirmed that not all of the risk management strategies are in place. For example training that has been identified has not been provided to all staff, including lone working, fire safety and de-escalation techniques. A torch is to be available. The home has a torch that was easily accessible but it did not work. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 22 The guidance and risk assessment focused on safety of the staff and the security of the premises. It did not reflect the impact of the changes upon the service users. There is no evidence that the service users care needs have been reviewed to reflect these changes. As noted earlier in this report the changes in the staffing ratios has had an affect the way that the service users care is provided, the times that medication is administered and the opportunities to access leisure and maintain skills. Observations during the inspection, discussions with the service users and information provided in comment cards confirmed that the service users like the staff and find them approachable. One staff member spoken with demonstrated a good understanding of her role, she stated that since she has been employed in the home she has received a lot of training, she was able to demonstrate that she had learned from this and changed her practice in line with the update in her knowledge. She demonstrated an enthusiasm for further training and development. Standards 34 and 35 could not be assessed on this occasion as the manager stores the records relating this securely. The manager was not present during this inspection. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home has a programme of review and development the service users can not be certain that the choices that they make will be acted upon. The home does not take sufficient action to promote the health and safety of the service users and staff. EVIDENCE: The organisation has a programme of review of the quality of the service provided. The quality assurance file included a development plan for 2004 – 2008. There is also a report detailing the homes progress towards meeting this plan. This report is not dated. There is also an action plan in place with timescales for addressing issues raised. There is no evidence in this file that these issues have been met. There is evidence that the service users views have been sought with regard to the service that is provided. This is in the form of a questionnaire. The questionnaires completed were not dated. It is noted that the comments made by the service users were positive. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 24 The home holds weekly meetings that also provide the service users with opportunity to express their views and make decisions about what they would like to do. There is little evidence to suggest that the requests made are facilitated. A sample of records relating to the health and safety of the home were examined and a tour of part of the home was undertaken. This provided evidence to confirm that the home takes some action to promote and maintain the health and safety of the service users and staff. Records showed that the staff undertake regular testing of fire alarms, there is evidence that the home also hold regular fire drills and make a daily check to ensure that fire exits are not obstructed. During a tour of the home it was noted that the fire extinguishers were last serviced on 10/09/05 one extinguisher had not been serviced since 10/09/04. There is a fire safety risk assessment in the health and safety file. This document has not been completed. There is no evidence in this file or following discussions with the staff that the fire safety procedure has been reviewed to take into consideration the changes in the staffing ratios. Records were available to confirm that the home stores food safely and that water temperatures are maintained at an acceptable level. As noted earlier in this report the organisation has undertaken an assessment of risk identified with reducing the staffing ratios. Not all of the strategies identified to reduce the risks are in place. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 1 X 2 X X 1 X Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 12 13(4) 18 (1)(a) Requirement The provider must ensure that there are sufficient staff on duty to meet the service users health and welfare needs in a way that they require and prefer. Timescale for action 30/10/06 2 YA6 15 This requirement also relates to standards 18, 19, 20, 33 and 37. 30/10/06 The provider must ensure that the service users have a plan of care that details the way in which care is provided and reflects the service users long term goals. This requirement also relates to standards 18 and 19. 3 YA9 13(6) 18(1)(a) The provider must ensure staffing rotas are planned to enable the service users to have a choice of male or female carer. In circumstances where this is not possible a full assessment of risk is to be DS0000004390.V306493.R01.S.doc 30/10/06 Cavendish Lodge Version 5.2 Page 27 undertaken and risk management strategies devised. This requirement also relates to standards 18, 19, 33 and 42. 4 YA12 12(1)(b) 16(2)(m)(n) The provider must increase the opportunities for service users to participate in activities that promote leisure and rehabilitation. This requirement also relates to standard 13. The provider must ensure that medication administration records detail the time that medication administered. The provider must ensure that service users who choose to self medicate are provided with secure storage for their medications. The provider must ensure that the cause of water damage in the bathroom is identified and remedied and repair the seal to the bathroom floor. This requirement also relates to standard 30. The provider must ensure that the service users are able to lock their bedroom doors if they wish. Broken or worn locks are to be repaired or replaced. The provider must ensure that curtains or blinds are provided where these are missing. The provider must arrange for replacement of the DS0000004390.V306493.R01.S.doc 31/12/06 5 YA20 13(2) 30/10/06 6 YA20 13(2) 30/10/06 7 YA24 23(2)(b) 31/01/07 8 YA24 23(2)(b) 30/10/06 9 YA24 23(2)(b) 16(2)(c) 23(2)(c) 30/10/06 10 YA24 30/11/06 Cavendish Lodge Version 5.2 Page 28 dishwasher and removal of condemned electrical items. This requirement also relates to standard 30. The provider must ensure that the hallway carpet is replaced. This requirement was made at the previous inspection of this home. 12 YA32 18(1)(a)(c) 13(4) The provider must ensure that where risk management strategies have been developed, these are implemented. This must include the provision of relevant staff training. This requirement also relates to standards 9, 18 and 42. The provider must ensure that a copy of staff identification is retained on file at the home, in all instances, when new staff are recruited to the home. 30/10/06 11 YA24 16(2)(c), 23(2)(d) 31/01/07 13 YA34 Schedule 4,6(b) 31/01/07 14 YA37 9 (2)(b)(i) This requirement was made at the last inspection – compliance could not be assessed on this occasion. The manager is required to 31/01/07 complete training for the Registered Managers Award and to inform the Commission for Social Care Inspection when she has achieved this qualification. This requirement was made at the last Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 29 15 YA39 12(2) 24(3) 23(4)(c)(i) 16 YA42 17 YA42 23(4) inspection – compliance could not be assessed on this occasion The provider must ensure 31/12/06 that when consulting with the service users the views expressed are acted upon. The provider must ensure 30/10/06 that fire safety equipment is serviced at regular intervals. The provider must 30/10/06 complete a fire safety risk assessment. This must take into consideration the planned changes to the staffing ratios. 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 YA32 YA22 Good Practice Recommendations Increase the number of staff trained in vulnerable adult abuse. It is recommended that the service users are re-informed of the homes complaints procedures. Cavendish Lodge DS0000004390.V306493.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. 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