Inspection on 12/12/05 for Cleaveland Lodge

This inspection was carried out on 12th December 2005.

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

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

Other inspections for this house

Cleaveland Lodge 04/09/09

Cleaveland Lodge 06/08/08

Cleaveland Lodge 03/07/07

Cleaveland Lodge 05/12/06

Cleaveland Lodge 16/03/06

Cleaveland Lodge 15/03/05

Cleaveland Lodge 03/11/04

Cleaveland Lodge 29/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Cleaveland Lodge 151 Rowhedge Road Old Heath Colchester Essex CO2 8EJ Lead Inspector Tim Thornton-Jones Unannounced Inspection 12th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cleaveland Lodge Address 151 Rowhedge Road Old Heath Colchester Essex CO2 8EJ 01206 728801 01206 728698 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) Ms Melanie Yanum Beefnah Ms Melanie Yanum Beefnah Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 54 persons) The external grounds to the rear of the premises are to be suitably landscaped within six months from the date of this Certificate 15th March 2005 Date of last inspection Brief Description of the Service: Cleaveland Lodge is a large family house that has been extended and improved over recent years to form the present accommodation, which is offered on the ground and first floor. There is a passenger lift to enable first floor access. In addition to the former extension to the premises, the home has recently been further extended to the rear, increasing the registered beds to 54. The service offered is to create a homely and comfortable environment for older people over the age of 65 years who require, or choose to live within, a care setting by way of their old age and associated needs. The home does not purport to provide accommodation and care for older people with special or complex care requirements. However, the Statement of Purpose does state that the home will accommodate service users, within the registration category, who wish to make Cleaveland Lodge a home for life, providing the service can continue to discharge its duty of care to the individual with or without community healthcare support. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At this inspection, 27 National Minimum Standards were inspected. Of these 3 were rated as needing minor improvement to fully meet the minimum requirement. This represents an approximate compliance level, based upon the standards assessed on this occasion, of 89 . This represents a further improvement since the previous inspection. The inspection concluded that most areas of National Minimum Standards continue to develop, with 4 National Minimum Standards not met previously now complying. The revised management structure has enabled a more focussed approach to ensuring that practice continues to develop. The commitment to staff training was demonstrable, although the availability of NVQ places locally has created some difficulty. Whilst all staff untrained to NVQ level are awaiting allocation of a training place, it is anticipated that the ratio of staff trained will increase by the time of the next inspection. The Registered Manager will need to complete NVQ 4 as speedily as possible. It is recommended this be achieved by 31st March 2006. Overall, this was a positive inspection with indications that the service is continuing to work towards compliance of National Minimum Standards. What the service does well: What has improved since the last inspection? • • • • Care planning. Quality assurance. Staff recruitment practices. Maintenance of statutory records. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 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. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 • Service users benefit from a pre-admission assessment process and have clear terms and conditions including a trial stay. EVIDENCE: The terms and conditions and contractual arrangements are set out in a separate document and are summarised within the Service Users Guide. The service has an admission procedure to help ensure compliance to National Minimum Standards and to help ensure that service users’ needs are likely to be met within the available resources. In addition, the home’s process is aimed to help ensure a smooth transition process. Based upon sample of the admissions undertaken recently, all had been subject to assessment by the local authority, prior to admission being confirmed. Service users are offered a minimum of one month in which to ‘test drive’ the home. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 • This group of standards continues to develop in a positive way. EVIDENCE: Care plans were sampled. The system continues to develop and the overall standard had further improved, which is positive. The plans were well organised and clear. The plans were clearly set out to address a broad cross section of needs, based upon a known model, and of those sampled, all of the required data was present. Care methodology was evident in the sample seen and was set against the decisions made. Further work will need to be undertaken to help ensure that staff maintain an objective and focussed approach to recording practices, although this had improved. See recommendations. The plans contained sound information and monitoring of healthcare needs. These were based upon regular GP checks, although not all the plans seen were at the same informative level. The Inspector suggested that various healthcare data be separated within the plan to improve the continuity of planning and recording. See recommendations. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 10 The practice of staff was observed, both directly and indirectly, and was noted to be supportive, consultative and friendly. GP services are provided by a nearby surgery, although service users admitted from outside the catchment area of the surgery are encouraged to retain their own GP if possible. The prescribed medicines were inspected at random. The monitored dosage system, supplied by a local Pharmacy, was secure and well organised. The administration record was well maintained. Care staff were observed undertaking tasks in relation to medicines and this was found to be reflective of safe practice. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 • This group of standards continue to develop and improve. EVIDENCE: Whilst the Inspector did not have opportunity to speak with service users’ relatives, service users were spoken with and they expressed satisfaction with their surroundings and the support they receive from staff. Some service users expressed that the building work had been noisy at times, although at the time of the inspection the building work had been completed, with the exception of works to the grounds at the rear. Service users, who expressed a view, stated the food provision was, overall, good. This was consistent with the home’s quality monitoring findings. The home employs an activity co-ordinator, although the person was not due to be in attendance at the time of inspection. Information was available to demonstrate that the home engages with visiting entertainers. None of the service users spoken with expressed an interest in going out from the home, although the Inspector was advised that a small number of service users do go out from time to time. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 12 Service users are able to receive visitors in private. Those who have chosen to live in a shared room are able to use one of the communal areas suitable for this purpose. The way in which communal areas were furnished, and the position of chairs, was conducive to positive communication. The home does not hold cash in safe custody on behalf of service users at the present time. Service users have access to all personal records, which are held in a way that is reflective of confidentiality principles and data protection. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 • Service users benefit from an established procedure for the management of complaints. EVIDENCE: The Manager has developed a complaint procedure that complies with National Minimum Standards. The service has not investigated any complaints during the period since the previous inspection. CSCI have not received or investigated any formal complaints about the service during the same period. None of the service users accommodated have been assessed as lacking capacity to make individual decisions, however, several services users involve their families as part of the decision making process regarding their care. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 • This group of standards have continued to develop in a positive way. EVIDENCE: The premises have recently been extended to form accommodation for up to 54 people. The new accommodation was not being occupied at the time of inspection, but was visited and most of the rooms seen. The extension meets with National Minimum Standards. The rooms are finished to a good standard and provide additional communal space together with additional and improved toilet and assisted bathing facilities. All of the new bedrooms have en-suite facilities. As part of the registration process, the buildings standards compliance regarding health and safety, fire detection, provision and standard of water and electrical installations were met as required by Council Building Control. There were no obvious health and safety hazards noted. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 15 Some occupied rooms were visited and reflected a homely and individual space. Service users are encouraged to personalise their rooms with their own possessions. The whole home, where visited, was found to be warm, clean, well organised and tidy with no offensive odours detected. The rear extension has created a large enclosed courtyard area. At the time of inspection this area had yet to be completed, but it is understood it will be completed by the time of improved weather and service users will be encouraged to use the area. The front of the property remains mainly laid to hard standing for car parking, although a new attractive wall and decorative gates have been added and this has improved the security for service users and staff. To the rear of the property, a large garden remains. At the time of inspection this was not usable by service users as building work continues to this part of the site. The Manager is planning to landscape the garden as soon as practicable. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 • Improvement was noted regarding this group of National Minimum Standards. EVIDENCE: The staffing numbers and skill mix have generally improved, with the management structure having been strengthened. The Manager has appointed two deputy managers who lead on different aspects of the service, including staff training and development practices. At the time of inspection, 3 carers were undertaking NVQ training and all other staff are awaiting commencement. It was acknowledged that the number of NVQ providers within the area has significantly reduced and therefore opportunities have become limited. The staff and management remain committed to staff training and development. The two deputy managers are currently undertaking NVQ at level 4 in care and management skills. Observed practice was in accordance with appropriate and safe care principles. Staff and service users communicated in a friendly and respectful manner. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 17 The Inspector had opportunity to speak with a visiting nurse specialist (continence management) who expressed that, during the ongoing visits to Cleaveland Lodge, an improvement had been noted over the last 12 months or so, particularly to the overall environment. The nurse specialist stated that staff presented as friendly and supportive of service users. Staff training in relation to the specialist area had been offered, but due to internal circumstances this had been cancelled, however, further training will be offered to help ensure that all staff have the necessary current skills and information to them. Staff recruitment practices were sampled and found to comply with National Minimum Standards. The required care hours for the number of service users accommodated amounted to 692, although none of the very recently registered rooms to the rear extension had been populated. The staff availability exceeded this and in addition there were support staff employed, such as cooks, cleaners etc. The staff training and development plans have recently been improved and updated using a revised format, although not all of the care staff information had been included on the new system at the time of inspection. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 & 36 • This group of standards have been further developed and improved since the previous inspection. EVIDENCE: The Manager, Mrs M Beefnah, has long experience of managing services for older people within a residential setting. The overall management approach has been overhauled since the previous inspection and now features a threeperson team. This was partly in recognition of the additional size of the service, but also to ensure that all of the management tasks are appropriately delegated to ensure a developing culture of compliance with National Minimum Standards. At the time of this inspection Mrs Beefnah had not completed a course of study leading to NVQ level 4 in care and management. This will need to be Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 19 completed as soon as possible to ensure compliance with standard 31. (See recommendations.) Quality assurance and quality monitoring continues to develop. The management have produced questionnaires and other data collection methods, and have produced a ‘results table’. The next stage is to undertake an analysis of these results, in the context of the service Statement of Purpose and Aims and Objectives. In order to meet standard 33 fully, the quality assurance and monitoring approach will need to be integral to specified predetermined quality performance targets. The home has introduced a revised staff supervisory structure incorporating a supervision contract and recording format. This approach, when fully implemented, will meet with the requirements of National Minimum Standards if undertaken with the appropriate frequency schedule. Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X X Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 OP33 24 Standard Regulation Timescale for action The Registered Person must 31/03/06 ensure that the quality assurance and quality monitoring systems meet with National Minimum Standards. The Registered Person must 31/03/06 ensure that each carer receives formal supervision to the minimum frequency, covering the topic set out in National Minimum Standards. This is a repeat requirement. The Registered Person must 31/03/06 ensure that an adequate proportion of care staff are suitably trained to NVQ level 2. Requirement 2 OP36 18 3 OP28 18 Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 22 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 OP7 Good Practice Recommendations It is recommended that the Registered Person develops recording practices to more fully reflect objectivity. It is also recommended that monitoring of healthcare be separated within the plan of care for improvement of continuity of information. It is recommended the Registered Person ensures that NVQ 4 is completed by 31st March 2006. 2 OP31 Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Cleaveland Lodge DS0000017795.V276025.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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