Inspection on 03/07/07 for Cleaveland Lodge

This inspection was carried out on 3rd July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cleaveland Lodge 04/09/09

Cleaveland Lodge 06/08/08

Cleaveland Lodge 05/12/06

Cleaveland Lodge 16/03/06

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 Diana Green Key Unannounced Inspection 3rd July 2007 10:0 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.V345016.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 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.V345016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleaveland Lodge Address 151 Rowhedge Road Old Heath Colchester Essex CO2 8EJ 01206 728801 01206 728698 cleavelandlodge@hotmail.co.uk 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 (0), Old age, registration, with number not falling within any other category (54) of places Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 54 persons) 21st March 2007 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 to accommodate service users over 65years of age and the same number of whom may have 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. The fees range from: £374.50 -£420.00 per week Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 1/08/07 Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection undertaken on the 3/07/07 and lasting 7 hours. Since the previous key inspection of 5th December 2006, additional random inspections had also been undertaken on 1st and 5th February 2007 in response to a safeguarding adults referral. The inspection process included: discussions with the manager, deputy manager, the cook, the laundry assistant, care staff, six residents, six visitors and a community psychiatric nurse. Feedback was also received through surveys and telephone contact with relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-seven standards were inspected and five requirements and four recommendations made. The manager, deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 6 Stronger links with the P.C.T and Social Services had been established. The assessment process had improved with more robust documentation to ensure residents’ individual needs could be met prior to admission. Potential service users were invited into the home for a day visit so that they could view the home and meet with residents and staff. Risks identified during the assessment process were reviewed every month and care plans updated. A senior member of staff has been designated lead for care planning which has ensured care plans are monitored and uopdated as needed. During the last 12 months there had been several major extensions which had improved the living environment for residents offering them more communal space and facilities. The premises had been decorated throughout and new carpets fitted. Staff have received training with support of the PCT. Moving and handling techniques had improved. Standards for medicines administration had improved and staff had received additional training. What they could do better: It is acknowledged that the home has good links with some health and social care professionals, however there are still some areas of multi-disciplinary working that need to be strengthened. Some relatives raised concerns that they were not always kept informed of changing needs. Social activities are limited. Care staff provided some seated exercise and board games but there had been no entertainment or outings recently. Relatives raised concerns at the lack of stimulation. Several commented on the garden areas that had been provided with tables and seats but was not being used for residents. Some health and safety risks were identified that needed action and some call bell leads were not long enough for residents to call for assistance. Staff hand washing facilities (liquid soap and paper towels) were not provided in en-suites and there were two rooms that had a smell of urine. Red alginate bags for handling of soiled linen were not provided. Efforts had been made to improve the administration and recording of medication but storage gave some cause for concern. There was no monitoring of drug refrigerator temperatures. A letter was received on 12/07/07 following the inspection that a number of issues raised at (medication, hand washing facilities, clinical waste, wardrobes, record storage etc.) had been addressed. Please contact the provider for advice of actions taken in response to this Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 7 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. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 8 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.V345016.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 1, 3 and 4. Residents were well informed and had their needs assessed prior to moving in to the home. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that met regulatory requirements and had recently been reviewed. Prospective residents and or their representatives were provided with copies prior to admission. Some were observed in residents’ rooms and copies were displayed in the entrance of the home for visitors’ information. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 10 The manager or deputy manager carried out pre-admission assessments. The pre-admission assessment process had improved with the introduction of a comprehensive assessment tool that enabled a full assessment of potential residents to ensure their needs could be met at the home. Also potential service users are invited into the home for a day visit to ensure that they are aware of the home and what the home is like. The home does not provide intermediate care. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled standards 7, 8, 9 & 10 The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed, but improved communication with their representatives was needed. Standards for medicines administration were good but action was needed to ensure safe storage. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous key inspection all residents’ care plans had been reviewed with the assistance of the local authority. A sample of five service users’ files were viewed. All files contained an assessment form completed on admission to identify needs and used to develop care plans. An appropriate range of care plans were present on the sample of files viewed, and these generally contained a good level of detail of the action required by staff to help the Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 12 person meet their needs. Risk assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, skin integrity/pressure areas, mental health, environmental etc.). Some risk assessments had been introduced following advice from social workers. There were plans to introduce a nutritional screening tool that staff had recently received training in its use. One senior care assistant had been designated responsibility to ensure care plans were reviewed and obtained up to date information from handover meetings. However there were several instances in the care plans viewed where residents’ changing needs had not been included: more contact with individual residents was therefore needed. Feedback from some relatives indicated that residents had some difficulty in understanding staff whose first language was not English and some spoke in front of them in their own language. The records confirmed that residents were referred to GPs, received chiropody treatment; had annual eye tests, attended outpatients as required and received visits from a community psychiatric nurse, social workers and a dentist also attended the home on request. It was stated that arrangements were being made to enable residents to have a choice of GP. Residents’ personal and health care needs were generally well and this was confirmed from residents and relatives spoken with. One relative said their loved one had been nutritionally at risk when first admitted to the home and that action taken had ensured their appetite improved and they had put on weight. It was good to seen that care plans included residents’ preferences and evidenced choices were enabled. Feedback was also received from relatives that they were not always kept informed where their loved ones had changing needs that required them to see a GP, to have a wound dressed or had fallen. Feedback received from healthcare professionals was that staff were helpful and had followed advice given with regard to care planning, risk assessment and meeting residents’ needs. However recent tensions with some professionals indicated that referrals were not always appropriate and further multi-disciplinary working was needed to ensure this did not impact on care of residents. There was no designated medication/clinical room. Medication was stored in two trolleys that were housed in the staff (lockable) office. Neither trolleys were secured to the wall as required. A domestic fridge was used for drug storage and was located in a separate room. No monitoring of either the room or the refigerator was being carried out and advice was given to ensure this was taken daily at different times of the day to ensure it did not exceed safe temeprature levels (25°Centigrade). The manager agreed to purchase a drug refrigerator as soon as possible. The home had medication policy and procedures but these were not readily available in the area and the procedures(viewed later) were not sufficiently detailed to provide clear guidance to staff. Three senior staff administered all medication at the home and had all received appropriate training. Medication was supplied through a local pharmacy in pre-dispensed packs and individual containers and appropriate ordering and disposal procedures were followed (procedures for Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 13 disposal of medication were robust). Advice was given to ensure that for prescribed creams, only the person administering the cream must confirm by their signature. There was no list of staff names with their signature and initials who were designated to administer medication. No residents’ photographs were held on the MAR sheet to ensure accurate identification, although a photograph of each resident was displayed on their room door. One resident was self-medicating and lockable facilities were provided but a risk assessment had not yet been recorded. The medication and records for four residents were inspected. All medication was present as prescribed and accurately recorded. Medication administration records (MAR) were well recorded. Two items of medication provided as drops and in liquid form had no date of opening to ensure they were not used after their expiry date. There were no controlled drugs in use and no controlled drugs storage cupboard available. The home had no CD register to be used in the event of controlled drugs being prescribed. Discussions were held with the manager who proposed using a storage room as a medication room which was cooler, more secure, and would enable all medication to be stored in one place. Staff were noted to treat residents with courtesy and dignity; however, there were a few instances where residents in communal areas were seen with their clothes ridden up, compromising their dignity: this was a particular issue when residents were being hoisted and transported in wheelchairs. Residents’ rooms were fitted with locks and a resident spoken with said they could have a key to their door if they wished. Residents and their representatives said that in the main care staff upheld residents’ privacy and dignity although one said that they did not think to change residents’ clothes when they spilled food on themselves. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15 The social and therapeutic activities are in need of further development to meet residents’ needs including those with a dementia. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that an activities co-ordinator had been recently appointed and would start employment once the appropriate checks had been undertaken. In the interim care staff were providing some activities including ball throwing (observed during the inspection), individual activities, board games, music and videos. A new flat screen TV was being purchased to enable those with a sight impairment to see the screen more easily. The local mobile library attended the home regularly and the manager said they had made Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 15 arrangements to use the Community Mini-Bus and two trips were planned for later this week. The new extension had a residents’ kitchen where they planned to hold baking sessions and other craft activities. One relative said that care staff spent time talking or playing games with the residents. However most relatives who completed surveys said they felt there was little stimulation, entertainment was no longer provided and there were no outings. The home had made recent changes to adopt more flexible visiting times. Visitors were seen to visit throughout the inspection and those spoken with said they could visit at anytime. Residents confirmed they could meet with their friends and relatives in private in their rooms. Representatives from different faiths attended the home as needed and arrangements were being made for one resident to receive communion. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, what to wear, meals, etc. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them, and residents were seen to be able to have keys to their room, in order to give them control over their personal space. Residents spoken with were generally positive about the meals served at Cleaveland Lodge. The main meal served on the day of the inspection comprised sweet and sour chicken with rice or fish cakes with mashed potatoes and vegetables, followed by treacle pudding and custard. The meal looked appetising, and residents were seen to be enjoying it. Hot drinks were seen being served during the day, and water jugs were observed in residents’ rooms. The home operates a weekly menu that was observed displayed for residents’ information. The kitchen was well organised with appropriate cleaning schedules in place. The cook advised that food was locally sourced with fresh meal from the local butchers and fresh fruit and vegetables provided daily. Menus viewed showed an appropriate range of meals, with choices available at all meals. One relative said the food is excellent. Another said “the cook will always try to accommodate their favourite meals.” Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 16 & 18. Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. Residents spoken to were clear that they felt able to tell someone if they had any concerns. The home had received several complaints from relatives with regard to the home’s request to complete a funeral plan. Staff had learnt from this and intended future consultations with relatives were made on an individual basis. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. The records confirmed that all staff had received training on protection of vulnerable adults. The deputy manager had also undertaken training by Essex Vulnerable Adults Committee (EVAPC) to become a trainer. There had been one allegation made since the previous key Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 17 inspection with regard to delays in referring a pressure sore and a lack of pressure relieving equipment. A full multi-disciplinary investigation had been undertaken and allegations made that the number of residents with dementia exceeded those for which the home was registered. The allegations were found unfounded and recommendations were made that improved working relationships between district nurses and the home were needed. Action had also been taken with support from the PCT to provide staff training to purchase additional pressure relieving equipment. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon standards 19, 22, & 26. Cleaveland Lodge is clean and well maintained but some infection control issues pose a potential risk to the safety of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had recently been extended to provide an additional wing. The premises had security entrance gates. The home was appropriately furnished for the client group, well decorated and well maintained. A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the kitchen, the laundry and the garden. Evidence of checks by the fire officer and environmental health officer were seen. The Feedback received from residents indicated they felt safe and secure. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 19 The first floor of the home was accessed by stairs and a well maintained passenger lift. There were grab rails, and aids in bathrooms, toilets and communal rooms. The courtyard gardens were accessible to wheelchairs and outdoors furniture (tables, chairs, parasols) were provided. However a relative said “they have a lovely courtyard garden but they never seem to make use of it”. The home had assisted baths and a wet room. Call systems were provided throughout all individual and communal rooms but some leads were not long enough to enable residents to call for assistance. Pressure relieving equipment was available and the district nursing service also provided specialist mattresses. Arrangements had been made to purchase additional pressure relieving equipment on the advice of representatives of the PCT. The home had its own health and safety policies and guidance. The home was cleaned to a good standard. One resident said they were very pleased with the cleaning of their room. One relative spoken with said that efforts had recently been made to ensure there were no malodorous smells in the entrance of the home. However two residents’ rooms on the first floor smelled of urine. Liquid soap and paper towels were not provided for staff hand washing in all toilets, bathrooms and en-suites. Tablets of soap and toiletries were also observed in bathrooms indicating these were used for communal use. Staff should be reminded of the risk of infection where toiletries are used communally. Clinical waste bins stored externally were found unlocked. The manager said they were not aware of this requirement and contacted the suppliers to ensure locks were provided. The laundry room is small for the size of the home. However a second laundry room had been installed as part of the new extension that was not yet in use. There were two washing machines, and a drier fitted. Protective clothing (gloves and aprons) was provided for staff but there were no water soluble bags or soluble stitched bags provided for any laundry soiled by body fluids to be placed directly in the washing machine and minimise risk of infection. Washing machines did have the capacity to carry out sluice wash cycles ensuring hot water temperatures reached were effective to deal with infected laundry. One laundry assistant provided laundry duties in the morning and care staff undertook laundry duties during the afternoon. This should be closely monitored to ensure this does not have a detrimental effect on meeting residents’ care needs. A relative spoken with said that there had been some problems recently with items of clothing going missing and colour mixing of fabrics. A resident also said that they found the standard of laundry good and earlier problems with missing clothing had been resolved. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 27, 28, 29 & 30. The staffing levels (skill mix, number and competence) were appropriate to the needs of residents. Recruitment practices were thorough and promoted the protection of service users. Staff are supported to develop skills and qualifications through an established training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 50 residents in the home (including 1 in hospital). Staffing levels were seen to be appropriate to meet the needs of residents and comprised 9 care staff. The manager and deputy manager were in attendance. There were also 2 cooks, 1 laundry assistant and 3 domestic staff on duty. Staff were observed to closely monitor residents in the communal areas and to spend time with individual residents during the day. Most residents spoken with said that staff responded quickly when they used the call bell. The home had 6 care staff with NVQ level 3 and 27 care staff with NVQ level 2 training. The percentage of staff with NVQ level 2 training was therefore more than the recommended 50 . Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 21 The recruitment process was robust. The personal files of four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff recently employed had completed the Skills for Care Common Induction Standards (records were not inspected). It was also stated that some staff employed for more than a year were following this induction system. The home had an established training programme. Records viewed confirmed that all had completed training on Protection of Vulnerable Adults. Training provided since the last key inspection comprised medication, dementia, moving and handling, first aid, fire safety, pressure ulcer care, food hygiene, loss/bereavement. The deputy manager had also undertaken 3-day manual handling course for trainers. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 31, 33, 35, 36, 37 & 38 The manager is supported well by senior staff in providing clear leadership throughout the home. The manager aimed to ensure good health and safety standards and took prompt action where issues were identified that posed risks to service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager/proprietor has owned and managed the home for a number of years. She is supported by two deputy managers (job share) who both have Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 23 the Registered Manager’s Award. There was evidence of some updated training. Cleaveland Lodge has a quality assurance system in place. The quality of the service is monitored through good communication with residents and their representatives. Anonymous service user satisfaction questionnaires are sent out annually and identified action taken to improve service provision as a result. The manager was readily available to residents’ representatives and this was confirmed in discussion with relatives. Residents meetings are held every 3 months. Action had been taken promptly to address issues identified through monitoring of complaints. Policies and procedures were regularly reviewed. All residents had an advocate/representative to manage their finances on their behalf. Personal allowances were held for two residents and the home had secure facilities for the storage of any money looked after on their behalf. The personal monies of these residents were inspected and found to be correct with records and receipts held. The home actively discouraged residents from bringing valuables into the home. All charges for services (chiropody, hairdressing etc.) were made through invoicing. The manager said that care staff received supervision every 6-8 weeks where they were able to discuss their practice and these sessions were recorded. This was also confirmed from the records sampled. Handover sessions were also held between each shift to discuss residents’ needs. All staff received an annual appraisal. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home had a health and safety policy and procedures for staff guidance. All staff received regular training updates in health and safety. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. gas, electricity certificates, lift, hoists, annual PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment fire alarms and emergency lighting, hot tap water temperatures, etc.). A number of risks were identified at inspection including wardrobes not fixed to walls, an uncovered radiator and unlocked clinical waste bins. Cleaveland Lodge DS0000017795.V345016.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 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 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement Timescale for action 31/08/07 2. OP12 16(2)(m) & 16(2)(n) To ensure the safe administration and storage of medication: 1.Monitoring of medication’ room temperatures must be undertaken daily and action taken when this is exceeded. 2. Temperatures of the drug refrigerator must be monitored daily. 3. Individual containers of medicines with a maximum life must have the date of opening recorded. 4. Medication trolleys must be secured. To ensure residents are given medication as prescribed: 1. Medication policies and procedures must be reviewed to provide more detail for controlled drugs. 2. A CD drug register must be provided. More social activities and outings 30/09/07 must be provided by skilled staff that ensures residents are stimulated and their lives are enhanced. This is a repeat requirement. DS0000017795.V345016.R01.S.doc Version 5.2 Cleaveland Lodge Page 26 3. 4. OP22 OP26 23(2)(n) 13(3) 5. OP38 13(4) Timescale of 28/02/07 not met. Call bells must be provided with longer leads that enable residents to call for assistance. To minimise the risk of infection: 1. Hand washing facilities (liquid soap & paper towels must be provided in all key areas (en-suites and laundry room). 2. Water soluble or soluble stitched bags must be provided to enable contaminated laundry to be placed directly in the washing machine. 3. The smell of urine must be removed from the rooms identified at inspection. To prevent the risk of accidents to staff and residents and risk assessment must be undertaken and: 1. Wardrobes secured to walls. 2. Radiators must be covered. 30/09/07 31/08/07 30/09/07 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 OP10 OP31 Good Practice Recommendations Staff should ensure residents’ privacy and dignity is not compromised when hoisting or transferring them by wheelchair. NVQ level 4 training in both care and management, or equivalent, should be undertaken by the registered manager. Cleaveland Lodge DS0000017795.V345016.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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