Inspection on 05/05/05 for Cavendish Lodge

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Cavendish Lodge 16/01/09

Cavendish Lodge 21/01/08

Cavendish Lodge 19/10/06

Cavendish Lodge 01/03/06

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 Maggie Arnold Unannounced 05 May 2005 09:00 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 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 Stationary 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 E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rethink Dawn Bicknell PC 8 Category(ies) of MD 8 registration, with number of places Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 December 2004 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. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection there were three staff members on duty of which one was a state registered nurse. What the service does well: What has improved since the last inspection? Due to the absence of the manager and locked staffing files, it is not possible to confirm that all of the requirements arising from the previous inspection had been addressed. These requirements will be included in this report. Although there were one or two minor concerns the overall hygiene within the home was of an acceptable level. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, Prospective residents are given information about the home and have the opportunity to visit Cavendish Lodge prior to admission. This helps prospective residents to make informed decisions as to whether they wish to live in the home. EVIDENCE: Two care plans and accompanying files were selected for scrutiny. Both files were very orderly up to date and easy to cross-reference. Records showed that the home and placing agency worked closely to make sure that prospective residents are well informed regarding the service and have every opportunity to visit the home prior to admission. Residents spoken to confirmed that they had visited the home prior to admission and this had helped them to make a decision. Residents also said that they were encouraged to make a number of visits to the home, including overnight stays, before making a final decision. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7, 8,9&10 Residents have individual care plans and accompanying risk assessments. The home offers opportunities for personal development and varied leisure activities. This works towards improving/ maintaining residents’ mental and physical well-being and a good quality of life. EVIDENCE: The care plans and accompanying records were clear and comprehensive and included risk assessments. Both care plans and risk assessments are regularly updated. Staff spoken to throughout the visit were very knowledgeable about the care needs and personal preferences of the residents. Residents spoken to said that staff discussed all aspects of their care with them. One person said that staff “ talked about all sorts of things with them. For example, “Why it was a good idea to try and get a routine going”. Throughout the visit residents were seen to participate in a variety of different activities. For example, attending a meeting, shopping, cleaning and attending a day centre/classes. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 10 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 standard(s) 11, 15, 16 & 17 Residents have opportunities for personal development, including appropriate personal, family and sexual relationships. Residents’ rights and responsibilities are acknowledged. The home encourages residents to have a varied and healthy diet. EVIDENCE: As a result of their mental health problems most of the residents experience some difficulty in forming and maintaining friendships and close personal relationships. Records seen and discussions with staff evidenced that the home works towards supporting the residents develop appropriate relationships. Residents spoken to said that the staff gave support and guidance when they were feeling angry towards someone or felt they were liked. One resident said that they could sometimes get “very angry with people” and the staff were very firm when telling them when it was not right to say or do something. The resident went on to say that they knew the staff were there to help them. On the day of the inspection, some family members called to take one of the residents to the family home for a visit. The family gave very positive feedback regarding Cavendish Lodge, saying that they were always welcomed Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 11 and that the home kept them appropriately involved. They also said “The home provided excellent care and couldn’t be bettered”. Residents spoken to also said that their rights and responsibilities are recognised. Some residents said that there was times when they didn’t want to do something, for example, get out of bed, and staff always talked to them and said why it was” important to try and stick to a routine”. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 12 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 standard(s) 19 & 20 The home works towards meeting the residents’ physical and emotional health care needs. The home has policies and procedures for the safe management of medication. However inspection of the medication and records combined with observations evidenced that some areas of the home’s present practice do not meet the required national minimum standards for the safe management of medication. EVIDENCE: Records seen and discussions with residents and staff indicated that the home is pro-active in ensuring that the resident’s health care needs such as mental health care needs and routine checks such as psychiatry appointments and dental and option checks are routinely undertaken. Discussions with residents and staff combined with records seen evidenced that risk assessments are undertaken to ensure the safe management of medication, including the appropriateness of self medication. For example, medication was issued to one resident at a time and the staff member gave the medication along with water to the resident whilst they were sitting in the office. The member of staff stayed with the resident whilst they took the medication Concerns arose regarding the medication room, which has recently been relocated to a large cupboard leading directly off the main office. The office at Cavendish Lodge is particularly busy and in constant use by staff and Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 13 residents. Additionally the medication room was a multi purpose room. For example, it contained various tools, documents and some staff members’ personal items. With two exceptions, the overall management of medication met the national minimum standards. Two items did not have dispensing labels or the name of the resident. The home must ensure that all medication, whether prescription or homely medication is clearly labelled. Details of the medication are to be recorded on the individual’s medication administration record (M.A.R.) sheets. The registered person must ensure that staff have facilities for changing and storage facilities for their personal belongings. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 14 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 standard(s) 22, 23 Risk assessments combined with discussions with residents and staff demonstrated that residents’ views are listened to and acted on. Staff files were not accessible so it is not possible to say whether staff recruitment and checks have been undertaken in accordance with the regulations. Lack of such evidence may result in the residents being placed at risk of abuse or harm. EVIDENCE: Residents spoken to said that staff listened to their views and tried “to help although staff sometimes said they wanted/didn’t want them to do something”. Residents also said that staff always said why they did/didn’t want them to do something. Discussions with the staff and observation of practice throughout the inspection indicated that the home works towards protecting the residents from abuse, neglect or self-harm. It is of concern that, due to the absence of the manager, staff files were not available for scrutiny. The fact that staff files were not available on the day of the inspection means that there was no evidence that the recruitment, support and training of staff works towards reducing the risk of abuse, self-harm or neglect of residents. Procedures must be put in place to ensure that all statutory records are available for inspection by the Commission for Social Care. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 15 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 standard(s) 24 Cavendish Lodge is generally well maintained and residents live in a safe and comfortable environment. With one or two minor exceptions the home was clean and hygienic. EVIDENCE: Cavendish Lodge is a large house located in a quiet residential street. The home, which has ample off the road parking, is within walking distance of the town centre. The home also has a good-sized secluded garden that was used by various residents throughout the day. The stepped access into the house and garden plus the lack of a lift means the home is not suitable for someone with significant mobility problems. A tour was made of the home and it was found to be generally clean and comfortable and free from offensive odours. The home has a large lounge/dining room and separate smoking room. All of the bedrooms are for single occupancy only with five of the bedrooms having an en-suite facility. With one or two minor exceptions all of the bedrooms were clean, homely and decorated in a way that reflected the needs and preferences of the occupant. A number of minor concerns such as grubby wash hand basins were noted but addressed immediately. A requirement to make good the damp patches in one Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 16 of the bedrooms remains outstanding from the previous inspection. None of the present residents require specialist aids or environmental adaptations. The laundry was also clean and orderly with potentially hazardous items such as cleaning materials locked away when not in use. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35& 36 Staff on duty at the time of the inspection were competent and well informed regarding the care needs of the residents and daily routine of the home. Due to the lack of access to staff files it is not possible to confirm that the residents are protected by the home’s recruitment practices and well supported and suitably trained and supervised staff. EVIDENCE: Three staff were on duty at the time of the unannounced inspection, one of whom was a suitably qualified nurse. The manager of the home was off duty. Two staff members were interviewed on a one to one basis. Both advised that they felt well supported and had undertaken both basic and specialist training courses. Staff said they had undertaken an induction programme and received regular supervision. Staff spoken to were knowledgeable regarding the needs and preferences of the residents. All of the residents spoken to gave very positive feedback regarding the staff team. Some residents identified certain staff as being particularly supportive and helpful. When one resident was asked what it was that they particularly liked about a staff member they replied” Because they treat me as normal”. Further discussion evidenced that the resident felt staff treat them “As equals and with respect”. Due to the manager being off duty no staff files were available for inspection. The manager must ensure that statutory files are always accessible to persons authorised to view them. As Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 18 noted in the Concerns, Complaints and Protection section of this report the lack access to staff records means that there was insufficient evidence to demonstrate that the recruitment, support and training of staff works towards meeting the needs of the residents and complies with health and safety in the workplace. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 &41 Records relating to the current residents are up to date and in good order. This works towards ensuring the welfare and safety of the residents. In contravention of the home’s procedures not all records of a confidential nature were securely stored resulting in the potential to compromise the privacy of individuals to whom the files related. The home has a comprehensive set of policies and procedures covering all aspects of care and requirements necessary to meet the needs of the residents, safety of staff and ensures the smooth running of the home. The present filing system results in some difficulties in locating all of the documents. This has the potential to put the safety of the residents and staff at risk and disrupt the smooth running of the home. EVIDENCE: As noted in the Individual Needs and Choices section of this report the home has well ordered files and information relating to the present residents. In accordance with Regulation 37 of the Care Homes Regulation 2001 the home also records and advises the Commission of any illnesses or incidents of concern. There was an unlocked filing cabinet in general office containing Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 20 archived files that contained previous residents’ confidential information. Other Rethink employees who are not employed to work employed in the home also use the office. The majority of the home’s policies and procedures are located in the office. A number of policies were missing from the files and could not be found. Although the staff were familiar with the various policies and procedures, for example, steps to be followed in the event of a fire, the documents must be easily accessible to new staff and as a prompt to the more experienced staff. Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish Lodge Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 2 x E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 22 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 20 Regulation 23 (3 A) 13(2) Requirement The present location of the medication cupboard must be reviewed. The medication cupboard must only be used for its designated purpose. Staff must be provided with changing facilities and storage facilities for personal items such as handbags and mobile telephones. Outstanding from the previous inspection. The registered person must ensure that records of checks made by the Criminal Records Bureau on staff working in the home are kept for inspection purposes and made avaiable in the home. Outstanding from the previous inspection. The responsible individual must ensure that at all times suitably qualified, competent and experienced staff are working in the care home in such numbers as are appropriate for the health and welfare of the residents. Outstanding from the previous inspection. The responsible individual must ensure two written referances are obtained Timescale for action 24/07/05 2. 23 7: Schedule 2 24/07/05 3. 18 33 24/07/05 4. 18 34 24/07/05 Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 23 5. 6. 17 (1)(b) 17(2) Schedule 4:15&16. 41 42 and followed up as nessary. Information regarding any dismissals or gaps in employment must be checked. Records of a confidential nature are to be securely stored when not in use. An audit is to be undertaken to ensure that all policies and procedures are easily accessible. 24/07/05 24/07/05 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 Good Practice Recommendations Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Cavendish Lodge E53 S 4390 Cavendish Lodge V225967 050505 stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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