Inspection on 16/03/06 for Cleaveland Lodge

This inspection was carried out on 16th March 2006.

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

Cleaveland Lodge 04/09/09

Cleaveland Lodge 06/08/08

Cleaveland Lodge 03/07/07

Cleaveland Lodge 05/12/06

Cleaveland Lodge 12/12/05

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 16th March 2006 10:00 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.V286286.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.V286286.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 Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (54) of places Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 54 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 6 persons) The external grounds to the rear of the premises are to be suitably landscaped within six months from 1 December 2005 12th December 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, six of which are registered to accommodate service users who require care by way of a dementia. 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 Statement of Purpose states 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.V286286.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken to complete the programme of assessment, of all National Minimum Standards, during the inspection period 1st April 2005 to 31st March 2006. The shortfalls noted at the previous inspection were reassessed. Since the previous inspection the home has completed an extension to the rear of the property and a refurbishment. The home now has 6 places specifically for those service users who require support and care by way of a dementia. The management team are now more established and various aspects of the home’s operation have been developed. Staff supervision and training strategies have improved. The inspection concluded that the service continues to develop positively and is anticipated to reach full compliance of National Minimum Standards in due course. What the service does well: • • Provide an decorated. environment that is comfortable, well furnished and Catering arrangements. What has improved since the last inspection? • • • • • The building works have been completed and the new facilities are available. Staff supervision. Quality assurance and monitoring. Health and safety monitoring. Staff training strategy. Cleaveland Lodge DS0000017795.V286286.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.V286286.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.V286286.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): 1, 4 & 6 • • Service users benefit from suitable information on which to make an informed choice about where to live. The arrangements inspected on this occasion conclude that the home demonstrates capacity to meet service users’ needs. • The service was not providing intermediate care needs for service users. EVIDENCE: The service has developed a Statement of Purpose and Service Users Guide, which have previously been viewed. The Registered Person confirmed that these documents remain in use and therefore continue to comply. Whilst not specifically reviewed again, the documents were evidently available and were in use. Service users are admitted to the service via the use of a care management assessment to which relevant professionals have been party. This was demonstrated via documents seen in relation to the most recent service user admissions. Cleaveland Lodge DS0000017795.V286286.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): 8 & 11 • Service users benefit from satisfactory arrangements to support their healthcare requirements. Revised arrangements within care plans improve the home’s approach to illness and end of life issues. EVIDENCE: Whilst specific care plans were not examined on this occasion, aspects of healthcare arrangements were reviewed. Sampled records indicated that primary healthcare arrangements were satisfactory, including District Nursing, Chiropody and GP services. The Inspector took the opportunity to speak with a District Nurse who was visiting at the time of the inspection. It was confirmed that of the 32 service users accommodated, 2 people were receiving relatively minor treatment. The District Nurse commented that from the nursing perspective the Community Team had noticed a steady improvement in the care outcomes at Cleveland Lodge over the preceding year or so. Care planning, regarding illness and end of life issues, has been revised and an improved recording system and practice had been introduced. The care plan Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 10 approach places greater emphasis upon service user choice and consultation regarding these potentially sensitive matters. The approach was used recently in response to the passing away of one service user. Cleaveland Lodge DS0000017795.V286286.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): 15 • Service users benefit from a varied, appealing and well planned diet. EVIDENCE: The kitchen, which has been refitted and improved as part of the building works recently completed, was visited. Fresh fruit was available. The menus were reviewed and indicated a well balanced and varied range of meals. Service users spoken with, who expressed a view, stated that the meals provided were good. It is recommended a more reliable method of recording the quantity of the meal consumed be used to improve the record of food served. This information can then be cross referenced to any particular dietary concern. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 12 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): 18 • Service users benefit from the home’s policies and procedures, although would be enhanced by a higher proportion of trained carers. EVIDENCE: The policy and procedure documents reflect sound practice regarding the Protection of Vulnerable Adults from abuse (POVA). The link between the service and the lead agency is made, although could be developed with additional information. See recommendations. Staff training is required to ensure that all carers completely understand the issues involved and a way of working that reduces risks to service users. It was noted that all of the staff are due to attend such training and two dates have been confirmed. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 13 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): None • Service users benefit from a comfortable environment. EVIDENCE: Premises standards were not specifically inspected on this occasion as the building has recently been extended and refurbished and was assessed at that time. At the previous inspection all of the relevant standards were assessed and found to meet with National Minimum Standards. A tour of the building was undertaken and on this informal basis the environment was well decorated, comfortable, free from any odours and adequately equipped. There were no obvious safety hazards noted. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 14 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 • • Service users do not fully benefit from a trained workforce. Service users benefit from the home’s recruitment approach and from satisfactory deployment. EVIDENCE: Documentation was examined in relation to the most recently recruited staff. All of the requirements had been met, however, where the POVA 1st check had been completed, the home had accepted telephone confirmation of clearance. It is recommended that improved information be obtained when undertaking this method to ensure that ‘tracking’ confirmation may be made. This was discussed with the Deputy Manager who suggested a revised form that the home could use for this purpose. The home uses a ratio calculation recommended by the Department of Health in relation to the deployment of staff. The most recent calculation indicated that a total of 692 hours per week was required. The staff roster was examined, which showed that 726 hours were routinely deployed. In addition to these hours are management, cooking and cleaning hours. The home also employs a part time activity co-ordinator. At the time of this inspection the home had encountered a staff turnover, leaving the home just below the required 50 of staff trained to NVQ level 2, although approximately 60 of the staff are working toward this qualification. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 15 Both deputy managers are working toward NVQ level 4 in care and management. Staff training and development strategies continue to develop and include an annual appraisal. Two staff were interviewed as part of the inspection process. Both stated they were content working at the home and received good support from management, including ongoing supervision. Both stated they considered service users to receive a good standard of care. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 16 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): 33, 34, 35, 36, 37 & 38 • • Service users do not yet fully benefit from the home’s quality assurance and monitoring approach. • • • Service users benefit from a well supervised care team. Service users do not fully benefit from the home’s record keeping. Service users benefit from the home’s approach to health and safety. EVIDENCE: The quality assurance and quality monitoring approach continues to develop positively and requires minimal work to complete the process. Consultation data has been collected and some analysis has been undertaken, although the results need to be set against an agreed level of quality (a quality specification) to ensure that the home is clear that they have achieved what they intended in terms of care outcomes. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 17 The home’s financial and accounting procedures were not inspected in detail on this occasion since financial references and other details were examined at the time of the recent extension and refurbishment. The Registered Person confirmed that a professional prepares annual accounts and budgets are adhered to. The home does not hold cash in safe custody on behalf of service users. The supervisory system has been developed since the previous inspection and is reflective of good practice, with good records being kept. The content of supervision sessions relate to National Minimum Standards. The frequency of sessions is on line to meet the 6 per year, per person. Record keeping was examined at random and was found to be compliant with the relatively minor matter of the staff roster. Completed records must be validated as accurate and where ‘shorthand’ is used, this must be subject to an identifying key. The home maintains a Care of Substances Hazardous to Health (COSHH) register and the management team undertake spot checks. There were no obvious health and safety hazards noted. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 N/A 3 2 3 Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Timescale for action The Registered Person must 30/06/06 ensure that care staff receive training in relation to the tasks and role they perform. The Registered Person must 30/07/06 ensure that an adequate proportion of care staff are suitably trained to NVQ level 2. The Registered Person must 30/05/06 ensure that the quality assurance and quality monitoring systems meet with National Minimum Standards. Requirement 2. OP28 18 3. OP33 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP18 Good Practice Recommendations It is recommended the record of food served be developed to provide an indication of the quantity of meal consumed. It is recommended that the Registered Person ensure that all staff undertake appropriate training linked to the prevention of abuse of service users. DS0000017795.V286286.R01.S.doc Version 5.1 Page 20 Cleaveland Lodge 3. OP31 It is recommended the Registered Person ensure that current NVQ 4 training is completed by December 2006. Cleaveland Lodge DS0000017795.V286286.R01.S.doc Version 5.1 Page 21 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.V286286.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!