Inspection on 21/01/08 for Cavendish Lodge

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 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 19/10/06

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 Martin Brown Key Unannounced Inspection 21st January 2008 09:00 Cavendish Lodge DS0000004390.V354286.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.V354286.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.V354286.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 F/P 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 vacant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 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 £419.20, this information was provided by the manager on 21st January 2008. Additional charges are made for some items. Information relating to these charges has not been provided to the Commission. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 21st January 2008, between 9am and 4pm. A relative of one resident was spoken with during the inspection, and was very positive about the service. Two relatives were seen and spoken with briefly during the inspection, and two relatives were spoken with by telephone after the inspection. All service users were seen over the course of the inspection, as were staff on both the morning and afternoon shifts. The acting manager was present throughout. A tour of the premises was made, relevant documentation was looked at, and observations of the interactions between residents, staff and their environment were made. Policies and procedures, and care records were examined, and three service users were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. Specific elements of other service users’ care were also looked at in detail. The Annual Quality Assurance Assessment, returned before the inspection, along with seven questionnaires returned by residents, and one by a visiting professional, also informed the inspection. Some service users were able to offer views in varying detail, on the care and support they received. These were broadly very positive. ‘I like it here’ and ‘this is the best place I’ve ever been’ were typical comments. Relatives were able to offer views on the care provided. These ranged from ‘reasonably satisfied’ to ‘very happy’ and ‘much better’. Staff, management and residents were welcoming and helpful throughout. What the service does well: A visiting professional recorded ‘provides a homely, relaxed atmosphere’ and works well to ‘socially integrate residents’. Relatives spoken with were positive about the service; one called it a ‘marvellous place’. Another said ‘We have a good laugh here’, and ‘I’m glad I moved here’. The only worry one resident could think of was the concern that ‘they might make the whole house non-smoking’. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 6 A common theme in comments from residents and relatives was of how much more settled people were since being at Cavendish lodge, how they liked it there, how much their lives had improved since being there, and, for many, how they wished to stay there. One relative commented; ‘it’s the best place he’s ever had. It suits him well, he is so settled there’. He also commented on how well the service worked with the health service. A perception of a much greater success rate for residents in avoiding acute hospital admissions since being at Cavendish Lodge was also an indicator of how the service was doing well. Several commented to the effect that this was the place where they had most stable. One person said: ‘I’ve been here three years without having to go into hospital – in other places I’ve only managed a few months.’ 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. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 7 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.V354286.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that they service will assess their needs in order to be sure that they can meet these needs. EVIDENCE: The acting manager advised that there have been no new admissions since the previous inspection, but that any future admissions would only be made following a lengthy assessment done in co-ordination with specialist mental health professionals, and involving visits, reviews, and trial periods to suit individual needs. He advised that admissions are only made through the local and health authority, and that privately funded admissions would not be considered. It was evident through looking at files of current residents that admissions take place following proper assessments and establishing that the service can meet individual needs. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect residents’ needs and are reviewed regularly. Clearer presentation of personal aspirations may help residents focus on positive goals. Residents are encouraged to take decisions and risks within a supportive environment, by staff who are familiar with them and their needs. EVIDENCE: A sample of three individual care plans were looked at. These outlined care needs and how they are met, and showed evidence of regular reviews and of involvement and agreement by residents, with specific agreements being signed by residents. One agreement concerned the management of monies. This was signed by the resident and a representative of the service, but was not dated. The acting manager said that these were relatively recent agreements, and agreed that they should be dated, so it was clear when the agreement was made. While care plans contained relevant information, and were regularly reviewed, the way information was stored in files did not make it particularly easy to Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 10 locate, as files did not appear to be ordered in a consistent way, with some information appearing at the front of one person’s file, appearing halfway through another person’s file. While this may not be a difficulty to the majority of the staff, who impressed with their thorough knowledge of individual residents, it could be a hindrance for newer staff trying to further their understanding a person’s needs. The manager agreed that a brief ‘personal profile’ of each resident, ideally written in the first person, would enable any new member of staff to gain relevant information about that person more quickly, as well as help to present that person, their needs and aspirations, in a positive light. Residents spoken with showed an awareness of their care plans, and of particular issues, such as, for example, eating well, and handling money. One resident acknowledged “I’m always part of my review, but I don’t always stick to my care plan. I sometimes need motivation.” Care plans tended to focus on needs, and less on individual aspirations. It was not clear from looking at care plans what individuals liked doing, hoped to do, or had enjoyed in the past. The people at Cavendish Lodge are not necessarily forthcoming about such matters. Residents spoke about their lives at Cavendish Lodge in positive terms, appreciating both the freedom and the support available when needed. Staff spoke of, and were seen to offer, a balance between motivating residents towards desirable aims such as developing self-help and social skills, and allowing them to make decisions. Specific areas of risks were assessed, with strategies for managing these being detailed. Staff showed, in discussion, and in interactions with residents, a good awareness of residents’ needs and how to respond to them. Staff showed a willingness to listen to residents’ concerns, and, where these were in danger of becoming very non-productive, or counterproductive, of deflecting them into more positive areas. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from improved opportunities to take part in social activities, enjoy healthy meals. There may be more scope for residents to be actively involved in preparing meals. EVIDENCE: There is opportunity for activities for appropriate activities for residents. Several residents commented that they did not wish to do more than go to the local shops, be able to smoke when they wished. However, when asked about such activities as a day trip to Weston-super-mare, residents spoke positively about them. Two residents were looking forward to a trip to Birmingham later in the week with staff. Most residents are currently able to go out by themselves, but limit themselves to areas and routines with which they are familiar and comfortable with. One resident said he enjoyed going to a particular pub for a soft drink, and did this regularly. Staff and management are aware of the desirability of encouraging residents in more adventurous activities, as part of enhancing their social and self-help skills and life experiences, and worked to do this within staffing constraints. One resident Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 12 wished for a walk ‘around the block’ with staff support. This request was able to be complied with almost immediately. Another resident spoke of regular visits to the gym. One relative spoke of staff ‘doing more on the social side’ in the past year, encouraging residents to go out more for meals and social events, as well as college courses. Residents talked of going to clubs and other social events, and that they are supported by staff, either directly, or by the arrangement of taxis or other transport. Relatives are welcomed in the home. Two visited during the inspection, and were made at home by the resident concerned. Residents showed a good awareness of the desirability of keeping communal and private areas clean and tidy. Residents all have lockable rooms and were conscious of keeping rooms locked and of respecting privacy. Staff were observed responding to residents in ways that enhanced their personal dignity, and encouraged them in taking responsible decisions. Lunch was taken with residents. This had been prepared by a staff member, and balanced healthy eating with items the residents enjoyed. Sandwiches were prepared to meet individual preferences, of which the staff obviously had a good knowledge, followed by ice cream. The majority of residents sat together to eat, in contrast to breakfast, which people had as they got up. One resident had enjoyed porridge, and was enjoying sandwiches and ice cream for lunch, which was encouraging, as weight gain was an identified aim for this person. Staff advised that on some occasions, residents are supported to prepare their own snacks, but this did not happen on this occasion. The evening meal was being freshly prepared by staff later in the day. Menus showed a variety of food being provided, with each day’s choice either being agreed by everyone, or at the request of one person in turn. Residents were all complimentary about the food. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ physical emotional and health care needs are supported in accordance with their needs and wishes, but their well-being is potentially compromised by the home’s current inability to evidence accurate administration of medication. Residents may be reassured by the acting manager’s commitment to resolving this. 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. ‘I’m quite happy with the staff’ was one comment during the inspection. One resident said, in appreciation of staff always being around if needed, ‘If I’m having a bad night I get up and talk to the staff’. ‘The staff are lovely’ observed another resident. 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. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 14 The manager advised that staffing is organised so that there is male and female staff on during the day. This was the case throughout the inspection. This cannot happen when there is lone working at night, but if additional staff are required because of escalating needs, then gender sensitivity is heeded. Care plans showed details of health needs and how they were met. Staff advised that when staffing numbers had been reduced, there were problems supporting residents to attend health appointments, but that this could now be achieved. Residents said that they received outside support when needed, and it was evident from records and discussion that multi-agency support was used when needed. As well as psychiatric support, advice and help from dieticians and incontinence nurses when required was evident. A questionnaire returned from a health professional noted ‘addresses health needs of residents’ and ‘liaises well with community mental health services.’ Discussion with staff and residents, and examination of files, showed good cooperation between the service and health professionals in monitoring and amending medication to achieve the optimum benefit for clients. One resident was currently in hospital, while a change in medication was being closely monitored. Medication was stored suitably, with a lockable fridge available for use if needed. One person, as on the previous inspection, self-administers medication. This is overseen by staff, in accordance with an agreed protocol, and random checks. All other medication is administered by staff. Protocols for ‘as required’ medication were seen. At the previous inspection, there was concern that medication was not being given out at set times. The acting manager advised that medications were given when residents got up in the morning and requested them, and at other intervals in the day, usually at the residents’ convenience, although there was some prompting in some cases. The packaging for the medication did not specify specific times, other stated night, morning, afternoon or evening. The acting manager advised that the priority was to ensure that residents consented to medication, and felt empowered to make the choice themselves. This was observed, with residents coming to request their medication. Medication Administration Record Sheets all had, bar one, a front page with a photograph of the person concerned, their date of birth, doctor’s details, and details of any allergies. The manager advised that the missing details, of the person who was self-medicating, would be included. Records indicated that medication was administered regularly. However, one dosage was seen to be remaining in one pre-packed container on one date, while the Medication Administration Record Sheets for that day was signed as if it had been given. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 15 The acting manager agreed that this was unsatisfactory, and agreed to look into it, query with the person who had signed it, and take any necessary action. There are a number of medications that are not dispensed in pre-packaged ‘blister packs’. These were not stock controlled on a daily basis, so there was no way of checking whether medications had been dispensed as recorded. In a sample box looked at, the amount remaining in the box did not tally with the original amount in the box minus the amount recorded as dispensed. The manager advised that this may have been because the there was some remaining from the previous month’s box, but this could not be evidenced. The acting manager advised that he would instigate daily stock control of all non-blistered medication as a policy immediately. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that their views are listened to and acted upon, and that they are protected from abuse, neglect and self-harm. A more ‘service –user friendly’ complaints information leaflet may assist residents in pursuing any complaints they may have. Staff training in abuse issues should further residents’ confidence that any such issues will be suitably addressed. EVIDENCE: No complaints concerning the service have been received by us in the past year. Residents all said during the inspection, or wrote in survey questionnaires, that they were happy with the service. The acting manager said they have received no complaints during that time. Two residents are likely to be accusative in the course their conversation. This was observed of one during the inspection, and was noted in individual care plans and risk assessments. One resident noted, philosophically; “We have our arguments”. When asked what would they do if they were unhappy about something, or if they had something they wished to complain about, residents invariably said that they would speak to staff or the manager. An organisational notice explaining the complaints procedure was on the wall, but this was not ‘user – friendly,’ being in small type, and not outstanding in any way. The acting manager agreed that something ‘snappier’ was needed. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 17 Relatives spoken with were confident that staff or management would address any issues raised, and showed awareness of the complaints procedure. Records of staff and residents meetings showed issues of concern being raised and responded to. Staff were due to undertaken Vulnerable Adult training. This need was highlighted in the previous inspection, and was rostered in for staff in the coming week. Risk assessments are in place in respect of particular abuse issues. Interactions observed between staff and residents demonstrated a positive, understanding, and transparent atmosphere helping protect against abusive practices. Residents now have control over their monies, collecting it, with staff support if they request it. Some residents ask for the service to put small amounts in safe keeping. This is signed for and recorded to safeguard residents. The acting manager advised that residents are managing well with the extra responsibility of handling their personal monies. A relative spoken with was pleased that residents were encouraged and supported to take more control over their personal monies. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from generally clean, uncluttered and spacious communal and personal areas, which are kept clean and tidy. Residents are poorly served, in some case, by poorly maintained window frames, and the downstairs bathroom is in a poor condition. There may be scope for encouraging residents to personalise their rooms more, by supporting them with purchasing of pictures or other items. EVIDENCE: There are two large front rooms. One is a lounge/ding room. The other is the designated smoke room, with a large extractor fan, that ensured that smoke went out through an exterior wall, rather than the rest of the house. The room to this room was kept shut, except for access. Both these communal rooms were pleasantly furnished. The kitchen, at the rear of the building, is spacious, clean, and well-equipped. Residents have access to the kitchen. Some cupboards are locked, primarily for safety reasons, as is the freezer. The fridge is accessible, containing items for drinks and snacks. It can be locked, in the event of there being particular problems in this area, but staff advised that this Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 19 has not been an issue for some considerable time. Residents were seen helping themselves to drinks on occasion, using the hot water urn in the corridor by the kitchen. Three residents were happy to show me their bedrooms. Bedrooms are able to be personalised according to residents’ wishes, although this did not appear to be a matter of great importance to some residents, with fairly bare walls, and one room featuring a couple of pictures that had ‘been there when I got here’, according to one resident. Refurbishment of some highlighted areas has taken place since the last inspection, with blinds being replaced, and a new hall carpet in place. Several window frames are in poor condition, and the one in the front upstairs bedroom requiring immediate attention. The manager advised that this would be done, and immediately contacted the estates department to action this. Windows have ‘limiters’ on them, to stop them being opened to an unsafe degree. The poor condition of the ground floor bathroom had been highlighted at the previous inspection. Although the immediate problem, of water damage, has been rectified, little has been done to improve the appearance of this very bare, functional, and uninviting room. The room has a ‘parker’ bath, originally installed for someone with specialist needs who is no longer at the home. The acting manager advised he would like to see this room greatly improved, and agreed that if a resident had an aversion to using a bathroom, the unattractiveness of this particular room would not help to overcome this. The extractor fan had a build-up of dust and ‘fluff’ on it. The cellar had been subject to flooding the previous summer. Additional protection has been put in place to prevent this happening again. The laundry room was busy, and showed signs of wear. Some of the flooring was split, following, advised the acting manager, a previous leak from a washing machine. He advised that this flooring is to be made good. Infection control measures were in place. The home was free from unpleasant odours. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from staff who understand and can meet their immediate needs. Residents have benefited from an improvement in staffing ratios since the last key inspection. Residents are supported by sound recruitment procedures; this is compromised if the service is not clear that all staff have had Criminal Records Bureau checks. Residents could be more confident that their needs were met by appropriately trained staff if there was comprehensive training matrix identifying training needs for the whole staff team. EVIDENCE: The previous key inspection expressed concern at low staffing levels. The staff rota was looked at. This confirmed that staffing levels in the day have reverted to acceptable levels that allow for sufficient staff to ensure residents can be accompanied as needed to essential appointments and that therapeutic and other activities to support and encourage living skills and enhance personal well-being can take place. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 21 There is only one person on duty at night, although the acting manager explained how this is increased whenever difficulties are predicted or experienced, or when residents are unwell. Staff confirmed this, although they had some reservations about whether this can always be anticipated, and whether putting additional staff on can send out provocative messages to residents. Appropriate procedures were seen to be in place to support safe and effective working at night, including ways to contact additional help, and to ensure residents’ needs were satisfactorily met. On the day of the inspection, there were two staff on duty, including the acting manager, in the morning, and two staff on duty in the afternoon, with an overlap of three hours in the middle of the day, allowing for additional activities then. The Annual Quality Assurance Assessment returned by the manager indicated that two thirds of permanent care staff had National Vocational Qualification level two, although the level was nearer one third amongst bank and agency staff. All staff spoken with demonstrated a good understanding of the needs of residents and how to meet them. Much of this knowledge was gained from working closely with the residents for a number of years. Evidence of training was shown by certificates in individual staff files, but there was no training matrix available to show how and when staff had been trained in mandatory and specialist areas, and whether all staff had received initial and updated training. Residents and relatives were complimentary about staff, comments including ‘the staff are always helpful’ Staff recruitment files were looked at. These were seen to be satisfactory, with application forms, references and Criminal Records Bureau checks in place. There was one exception to this noted: a person who had been employed for a number of years, who had had a police check prior to 2002, which had not been followed up by a Criminal Records Bureau check. The acting manager followed this up, and was able to confirm that a Protection of Vulnerable Adults check had been done, but not a Criminal Records Bureau check. He accepts that this must now be done. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents appreciate an acting manager who is approachable and available. In the long –term, they would benefit from a permanent, registered, manager to be able to further develop the environment, training plans and long–term development of the service to fully gauge, be led by and to meet the residents’ best interests. EVIDENCE: The home does not currently have a registered manager, since the departure of the previous manager after a six month probationary period. Currently the service is being managed by an acting manager from a sister home. The acting manager is a Registered Mental Health Nurse. Residents and staff spoke favourably of the acting manager, with one typical comment from a resident being ‘he’s a good manager’. An open door policy was noted, with residents frequently coming in to the office to discuss problems or simply to say ‘hello’. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 23 A fire risk assessment was seen, and had records of regular fire equipment tests. This recorded the last fire drill as just over a year ago. The manager advised that one had been done the previous week. This was confirmed by a staff member, but had not been recorded in the fire risk assessment. The staff member thought it had been recorded, but could not locate where. The manager advised that he would ensure it was recorded in the correct place. Staff were aware of what to do in the event of the fire alarms sounding. Records showed regular satisfactory testing of water temperatures and fridge and freezer temperatures, as well as a satisfactory annual gas check by a qualified person. A ‘bronze’ award for hygiene and safety had been awarded by the local environmental health agency in the summer, indicating satisfactory standards. Copies of Regulation 26 visits by the registered provider, and of residents and staff meetings were seen, demonstrating how issues were raised and addressed, such as refurbishment requests, and activities for residents. The acting manager said that, as an acting manager he had not been involved in any Quality Assurance schemes beyond that. The acting manager also felt some frustration at not being able to get the landlord or the organisation to act faster to improve the environment, particularly the bathroom and window frames, and felt that residents might benefit from a permanent registered manager in this respect. Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 24 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 3 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 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 25 no 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 YA20 Regulation 13(2) Requirement The dispensing of all medication must be accurately recorded, to ensure that the well-being of residents is not compromised. ‘Non-blistered’ medication must be stock controlled on a daily basis, to ensure that any errors can be immediately noted and rectified. Splits in the flooring of the laundry must be made good, to ensure the health and safety of all in the home is not compromised. Rotting window sills must be made good, with priority being given to the front bedroom, so that residents’ well-being and safety is not compromised. To ensure the protection of all at the home, all staff at the home must have a satisfactory Criminal Records Bureau check. There must be evidence that fire drills have taken place at DS0000004390.V354286.R01.S.doc Timescale for action 23/02/08 2. YA20 13(2) 23/02/08 3. YA24 23(2)) 23/02/08 4. YA24 23(2) 23/02/08 5. YA34 19(1) 23/02/08 6. YA42 23(4) 23/02/08 Cavendish Lodge Version 5.2 Page 26 appropriate and agreed intervals. 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. 3. Refer to Standard YA6 YA6 YA22 Good Practice Recommendations Residents’ well-being may be further helped by ‘user friendly’ information in care plans focusing on individual aspirations and likes. Any agreements signed by residents should be signed, so that it is clear when the agreement was made. A more ‘user friendly’ notice concerning the complaints procedure would help residents be more aware of how to complain if they were not happy about an element of the service provided. A matrix showing staff training would help identify training shortfalls more readily, so helping ensure residents’ needs were met by a comprehensively trained workforce. More detailed Quality Assurance procedures may help identify more clearly the successes of the service, and the hopes and whether it is meeting current and prospective needs and wishes of residents. For the home to further progress the best interests of residents, a permanent registered manager is needed. 4. YA35 5. YA39 6. YA42 Cavendish Lodge DS0000004390.V354286.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 77 Paradise Circus Queensway Birmingham B1 2DT 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. 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