Inspection on 04/09/09 for Cleaveland Lodge

This inspection was carried out on 4th September 2009.

CQC found this care home to be providing an Good service.

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 06/08/08

Cleaveland Lodge 03/07/07

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Cleaveland Lodge 151 Rowhedge Road Old Heath Colchester Essex CO2 8EJ Lead Inspector Louise Bushell Key Unannounced Inspection 4th September 2009 10:15 DS0000017795.V377512.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Cleaveland Lodge DS0000017795.V377512.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 Asha 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.V377512.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) 6th August 2008 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. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of the inspections undertaken by the Care Quality is upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was case tracking which involved selecting a number of people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The last key inspection took place on the 6th August 2008. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Care Quality Commission. We looked at the last Inspection Report and information on safeguarding and complaints since the last inspection. We also looked at the previous Annual Quality Assurance Assessment (AQAA) and reviewed what the service has improved in the last twelve months and its plans for the next twelve months. During the visit information was gathered directly from the staff, people who use the service and relatives and or visitors to the service. The visit took place between 10:15am and 16:00pm. This enabled the inspector to directly and indirectly observe the care practices and the day to day operations of the service. A selected tour of the building was conducted during which the inspector spoke with people who use the service, staff and visitors and the Registered Provider. What the service does well: People who use the service and visitors said that staff spoken to them in a friendly fashion, with respect, and they welcomed visitors to the units without restrictions. Premises and accommodation visited were well maintained and decorated. Garden areas provide pleasant areas for people to sit outside. Rooms visited were personalised. Positive engagements and interaction were directly observed between the people using the service and the staff. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 6 The staff at the service have introduced some appropriate methods to support the needs of those with Dementia. Staff are trained well ensuring that they have the correct skills to meet the needs of the people using the service at all times. One person using the service stated “I like it here, the staff are kind and we get lovely food”. Medication systems are well managed and people are fully supported in the safe administration of their medication. Activity provision for the people who use the service is thoughtful and stimulating. People are encouraged to engage in meaningful activities and thought has been given to the allocation of rummage boxes. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Cleaveland Lodge DS0000017795.V377512.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.V377512.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are assured that their individual needs are assessed, ensuring that the service is able to meet their needs. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives of the service, and includes a guide, which provides basic information about the service and the specialist care that is available. The guide details what the prospective people using the service can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 10 All people who use the service are given a copy of the guide. When requested the service can provide a copy of the statement of purpose and guide in a format which will meet the capacity of the resident. One person using the service stated, “I like it here and I had lots of information about it”. As part of the inspection process surveys were sent to a number of people who use the service. Twelve surveys were returned to us. All of the people responding, with support, commented that they received enough information to help them decide if the service was the right place for them before they moved in. The previous AQAA completed by the service stated “we have impliement a number of tools to ensure all service users are montiored and assessed in all aspects such as Malnutrition Universal Screening Tool (M.U.S.T), Tissue viability. All risk assessments are reviewed every month and care plans updated”. During the inspection it was observed that these initail screening tools were in place and formed part of the ongoing assessment process for the individual. Admissions are generally not made to the service until a full needs assessment has been undertaken. A skilled and trained person completes the assessment prior to admission to the service. The initial assessment document is detailed and appropriate to the policy and procedure in place. The assessment explored areas of diversity including preferences, religious and cultural needs, involvement from family, partners and advocates, race and disability. The format of the homes assessment document sets out in sectioned elements of daily life, their past history, and general wellbeing. The sections have prompts associated with each area to support the person carrying out the assessment in gaining the most detail during the assessment meeting. The initial assessments that were completed contained enough information in order for the care staff to support the person with their support and care needs. It was noted however that numerous sections of the initial assessment were blank or sparse with information. For example it was noted that the initial assessment does not explore in detail the preferences of an individual, including their cultural and diversity needs. The assessment section of the file did however contain a life history. It was noted that the service is also in the process of introducing a “Quality Check” document. This document aims to quality assure the admission procedures into the service. Whilst these documents could be of benefit to the service, those seen were not fully completed and where gaps had been identified no further actions had been taken to resolve or amend the recording. This was discussed with the Registered Provider as part of the feedback session who commented that the document was a new system and it is hoped to be implemented fully over a period of time. During the inspection people were directly observed having their individual preferences and needs met. For example one person was observed being supported with their meal and the care worker was providing support in a manner and pace that suited the person. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 11 Part of the inspection involved case tracking four people. We reviewed all four people’s initial assessments. It was found that three people had a completed initial assessment held on their file and the fourth person did not have one. Of the four people case tracked all four people had an assessment that was completed by social services. It was however evident that one person’s assessment completed by social services had been received following admission to the service. The service has the capacity to support people who use the service and responds to diverse needs that may have been identified during or after the assessment process. Information was freely available throughout the service and one person commented “Melanie came to visit me three times before I moved in here”. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that their primary emotional, health, social and psychological needs are being met and that staff are able to understand their needs as required. EVIDENCE: A total of four care plans were case tracked fully, it was established that people who use the service receive personal and healthcare support using a person centred approach. The care plan is generated from the pre admission assessment and includes clinical guidelines, risk assessments for the management of falls, bed rails, manual handling and self medication. The forms sets out areas of daily living including communication, being safe and risks, personal care, dressing, eating and drinking, sleeping and walking, mobility, dexterity, recreational, expression of sexuality, spiritual and cultural, vision and hearing and housekeeping. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 13 The sections contain a description of the person’s ability in each area, the level of support staff will need to provide and how this should be done. There were secondary care planning sheets that contained information about other areas of need not covered in the main plan. In an example seen these included paranoia, aggression, hearing loss, bathing, continence, personal care and agitation. There was a good general level of information about the person and where staff may expect to need to support them, although the instructions were not so specific as to give detail of how. There were some risk assessments in place in the care plans sampled. These included moving and handling assessments, assessments relating to the risk of falls and Malnutrition Universal Screening Tool assessments (MUST). In the main staff office there were separate records held of each person MUST and water low records. These were seen to be completed monthly. The service has a number of reviewing documents in place. Whilst in the main it was evident that care plans and assessments were being reviewed it appeared that the service was reviewing systems twice. This was discussed with the Registered Provider and the new Deputy Manager of the service to establish whether the process is accessible, meaningful and non tokenistic. The service had established evidence where people had consented to their care plans and the administration of medicines on their behalf; however it was noted on a number of occasions that these documents were blank. Detailed manual handling, environmental and mental heath risk assessments were in place and had been reviewed monthly. These documents identify the over all risk rating associated to a particular task for a specific person, however it was noted that the over all risk rating had not been completed and no further action has been taken to address the risk. It was observed that personal support is responsive and tailored to meet the individual choices, needs and preferences. Staff were directly observed to respect the privacy and dignity of all people. One person using the service commented “I like the staff, they are alright”. The service listens and responds to individual choices and decisions about who delivers their personal care. Staff were directly observed asking people to make active choices throughout the inspection process. People were observed having positive engagements with each other, visitors and staff. People are supported and helped to be independent and can take responsibility for their personal care needs. Residents have access to healthcare and remedial services. The health care needs of residents unable to leave the service are managed by visits from local Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 14 health care services. Clear evidence was seen in the care plans of specialist health care support services visiting the service and in addition to the care plan there were detailed notes made by the specialist visiting the service for example the District Nursing team and General Practitioners. A number of comments were received directly from people that use the service, their relatives and friends. A number of comments have been received that have determined that the care is provided to meet the needs of the people who use the service. One professional visiting the service at the time of the inspection commented that “I think its ok here….they always seem well looked after and support people to attend their medical appointments”. In addition to this a further professional who visits the service responded that the people’s social and health care needs are properly monitored, reviewed and met by the care service. The previous AQAA states “the care plan is used to ensure appropriate care is delivered for the individual and there specific needs. The care plan is then monitored and reviewed every month with the residents and relatives input”. All of the people surveyed responded positvily in relation to recieving the care and support that they need. The service has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. The management of controlled drugs is effective with records being accurate and stock balances being correct. A total of four people’s medication was case tracked in order to ensure compliance. Fridge temperatures were being recorded. Ordering and returns documentation was up to date and accurate. The service works with individuals regarding any refusal to take medication. The people using the service are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. Thought has been given to providing safe but sensitive facilities for keeping medication. The service has a good record of compliance with the receipt, administration, safekeeping, and disposal of medicines. Staff have completed and passed an appropriate medication course. An assessment has been carried out to ensure each member of staff is competent to handle record and administer medication properly. A number of bottles and box’s were observed not to have a date of opening on them and a hand written entry on the Medication Administration Record (MAR) had not been double signed and checked by two staff. A pill counter was not available whilst auditing medication. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their life style, and are supported to develop their life skills, ensuring that social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: People who use the service have the opportunity to develop and maintain important personal and family relationships. Feedback from a person using the service determined that their family members visit on a regular basis. One person commented “my family visit me when they can”. Another person using the service commented “it’s quite good here, we do quite a few things, and I like doing puzzles”. When the inspection commenced it was noted that a number of people were in the main lounge area, listening to old time music, singing and clapping and playing giant connect four. The feeling and atmosphere within the service was jolly and engaging a number of people for a significant period of time. The service has allocated hours for an activity coordinator. However at the time of the inspection these hours were vacant. The Registered Provider stated that recruitment was ongoing and that in the Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 16 absence of the coordinator staff were completing and providing activities. This was further evidenced through discussions with staff. One staff member commented “we try to do as many activities as we can to stimulate them”. The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. This was directly observed in the manner and the approach used by the staff team. Staff were directly and indirectly observed to respect and dignify each person they were supporting at all times. People were offered choices and supported to be as independent as possible. One person using the service stated “the staff do their best; they are very kind to me”. It was observed that the people using the service had positive engagement with each other and the staff supporting them. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. A good practice example was observed where a person using the service was walking around the building with a duster cleaning as she went and another person was observed wiping tables down after lunch. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. Other support may be offered in the service by a skilled and trained team. A variety of activity equipment was observed throughout the building with rummage boxes located in the main lounge for people to utilise. A large collection of books were available as well as other activity equipment. The previous AQAA states “a wide range of activities are on offer to all services users daily such as board games, cards, Afternoon films, exercises etc. Musicians and therapists visit the home regularly as well as local religious groups, also mini bus trips are made available for service users where they can visit local attractions with and aid of carers”. Resident meetings are commencing and the manager and the staff feel that this will further empower people who use the service. The service’s action plan following the internal annual quality assurance system, determined that twelve people thought that the provision of activities was fair, thirty three thought the provision was good, with three people describing it a excellent. Feedback received from a survey commented in relation to what the service does well and stated “taking care of resident’s needs and personal care. Supporting the residents needs at all times. Having regular activities for the residents”. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. It was observed that the meals provided were tailored to the individual preferences of the people using the service. There is a large white board in the dinning room area. This Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 17 is used to display the date, day and food available. However on the day of the inspection the meals choices were not well displayed and written in a style which was difficult to understand and would not necessarily meet the needs of a person with dementia. This was discussed during feedback with the Registered Provider and the Deputy Manager. Those people spoken with during the inspection could not always remember the choice they had made, but were confident that they would enjoy the meal. The manager said that staff asked people the day before for their preferences and these were recorded. In some cases the staff made decisions on behalf of people who were unable to indicate based on their previous preferences. The service does not use any other method of helping people express their choices for meals, although the manager stated that picture menus had been used in the past, these had not been found to be successful. A record of people’s choices was held in the kitchen and refereed to when serving the meal. Cold drinks were served during the meal and people were asked for their choice of drink. The care staff were directly observed being sensitive to the needs of those residents who find it difficult to eat and give assistance and support as required in a respectful manner. They are aware of the importance of supporting the person at the pace of the individual, making them feel comfortable and unhurried. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a robust complaints procedure in place, good staff awareness and attitude towards safeguarding issues so people who use the service are safe and protected. EVIDENCE: The service has an open culture that allows people who use the service to express their views and concerns in a safe and understanding environment. People who use the service have commented that they are happy with the service provided; feel safe and well cared for. A number of comments received determined that people who use the service and relatives and friends are aware of what to do if they have any concerns. One person who uses the service stated “if I was unhappy I would always talk to staff”. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the service and is displayed in a number of areas within the service. There is a detailed record of all complaints and compliments made and received. It was noted that the service does not have many complaints or verbal complaints recorded. The Registered Provider stated that this is due to the people using the service being happy and not needing to complain. The nature of complaining was discussed and it was highlighted that people can make verbal Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 19 complaints. Currently the service does not have a system for recording the non formal verbal complaints to ensure better outcomes for the people using the service. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff commented that they have received training in safeguarding and felt confident in reporting any issues as they occurred. Staff had a clear understanding of the Whistle-blowing policy and when the use of this may be put into practice. During the inspection it was observed that a number of training sessions were arranged for staff in the safeguarding of vulnerable adults. The service understands the procedures for safeguarding adults and attends meetings or provides information to external agencies when requested. There has been one referral made in the previous twelve months. This is now resolved in full with no action being taken. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can not be sure that they are kept safe at all times. EVIDENCE: The premises have been improved and extended over a period of time to the present provision that provides for a number of communal facilities and bedrooms with en-suite facilities. The building is maintained to a satisfactory standard both internally and externally. Although there are not any records of refurbishment programme, there was evidence of redecoration and replacement of furnishings and fittings as required. It was brought to the attention of the Registered Provider that a Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 21 number of rooms on the first floor required updating in the furniture that was provided. The building has been progressively altered over the period the proprietors have owned the home, with additional wings being added to the main building. These contained additional communal spaces, bathrooms and toilets and bedrooms. The building is connected by a continuous corridor which if followed comes full circle to the front of the building. The premises are tastefully decorated with muted tones on all walls and paintwork. Some signage is used for example people’s names and photos are used to identify their rooms. Memory boxes were not in place. During the visit to the service, people were observed walking about the environment opening doors and entering and leaving bedrooms freely. The lay out of the building ensures that people are able to walk freely and are safe. It was noted that a number of bedroom doors throughout the building were not compliant with fire safety and did not fully close. A number of doors were observed to be propped open with a variety of objects including stone garden ornaments. During the inspection action was taken to close these doors. The service’s annual quality assurance determines that twenty three out of forty eight people thought that the decoration and ambience was good with a further thirteen people commenting that it was excellent. During the inspection time was spent in the kitchen area. It was observed that the kitchen in design was domestic. An industrial cooker and fryer was available. Discussions occurred with the chef, who stated that the “kitchen works very well”. It was noted that there was a preparation table in the centre of the kitchen area. This had an area which had become worn and was not effective for good food hygiene practices. This was brought to the attention of the chef and the Registered Provider. The door to the kitchen area was also propped open. The deep fat fryer was located to the side of the kitchen area and placed on top of the kitchen work surface. It was observed on one occasion that a person using the service tried to enter the kitchen area. The kitchen area was very clean, ordered and tidy. Records were in place for the cleaning of the kitchen and the temperatures of the fridge and freezers were up to date. It was noted that a small number of items in the fridge were opened but did not have a date of opening on them. This was brought to the attention of the chef who took remedial action. The kitchen had a small bin available, however this was not a pedal bin and could increase risk of contamination and cross infection. It was also noted that in the small communal lounge that the carpet had lifted in several areas causing a trip hazard for the people using the service, staff and visitors. The laundry facilities provided sufficient equipment for the needs of people living at the service and equipment was in compliance with infection control Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 22 requirements, however the lay out of the laundry could be improved to ensure it meets the most recent advice from the Department of Health (DH) that can be found in their publication ‘Infection Control Guidance for Care Homes’. For example there was one entrance where soiled laundry came in and the same entrance where clean laundry was placed. There were not any noticeable odours at the time of the inspection and staff were observed using equipment to protect people from infection. There were soaps and towels in place in toilets around the service. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service can be confident that staff in sufficient numbers to meet their needs supports them and who have received training to carry out their roles. EVIDENCE: There were fifty three people living at the service at the time of the inspection, with one vacancy. Feedback from the people who use the service shows that they have confidence in the staff who care for them. Staff Rotas were seen and displayed adequate numbers of staff on duty to meet the needs of the people using the service. Specific attention was given to the busier periods of the day. A Deputy Manager was usually on shift and supernumerary to the care staff as well as the Manager of the service. This enables staffing levels to be maintained for the safety of all and that record keeping was completed and monitored as required. Staff members are able to undertake external qualifications beyond the basic requirements. Training was seen to be available to all staff during the inspection with numerous courses being made available for all staff to attend. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 24 This included Dementia Care, Continence Care, Deprivation of Liberty and Safeguards, Mental Capacity Act. There is also an information board in the staff office area which is central to the main communal areas of the building. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. People who use the service report that staff working with them are very skilled in their role and are consistently able to meet their needs. One person using the service commented “the staff are always kind”, whilst a further person commented “the staff are quite nice”. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. A total of five staff files were audited and were seen to contain all the required documentation. The previous AQAA states “Cleaveland Lodge employs a high number of staff that are very caring, considerate and always work towards the service users best interest. All staff are CRB and POVA checked before employment and two references are obtained inline with care standards. The numbers of staff at any one shift is calculated using a formula divised to take into account the number of service users , their dependency and needs. Staff are trained and supervised thoughout their time at Cleaveland Lodge and management always push staff to set goals and achieve high standards and opperate good practices”. Four individual staff commented on the strong team culture of the service and felt that following recent recruitment, there are enough staff on duty to meet the needs of the people who use the service. Staff confirmed that the service was clear about what was involved at all stages and was robust in following its procedure. Once recruited staff receive induction and training. The induction programme is then signed at the end of each stage. These were evident on most of the staff files that were reviewed. Staff confirmed that the senior team provide supervision. Records showed that people are receiving supervisions, however these may also be group supervisions. The mix of staff is suitable to meet the cultural needs and mix of people that use the service. Staff reported that they felt supported in their roles and that they were able to discuss issues with a member of the senior team if required. A comment received from a staff member stated “most of the managers are very supportive, they listen to me and I feel really respected by them. The rest of the staff team is very supportive”. In addition to this a further staff member added that we always have detailed handovers and we are always aware of and told about people’s needs”. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home can be assured that an experienced management team supports the service. EVIDENCE: The manager Asha Beefnah had taken over the manager post from Mrs. Melanie Beefnah in 2008. Ms Beefnah has worked for 11 years in care settings, and has qualifications in GNVQ health and social care, BA Honours Degree in Hospitality Business Management, train the trainer and has now completed the NVQ level 4 Registered Managers Award. Ms Melanie Beefnah continues to be heavily involved with the service and remains the Registered Provider. The Registered Manager and the deputy manager have a clear understanding of the Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 26 key principles and focus of the service, based on organisational values and priorities. They work to continuously improve the service. Feedback received on the day of the inspection from staff and as part of the feedback questionnaires received determines that the management are effective and approachable. The AQAA states “Cleaveland Lodge is run by a very competent and well qualified group of managers with various fields of work experience. The management team at Cleaveland Lodge always work hard towards providing a high standard of care and put the interests of the service users first. Management work closely with all staff within the home and always offer guidance support and training”. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has sound policies and procedures, which are corporately and internally reviewed and updated, in line with current thinking and practice. The manager ensures that staff follow the policies and procedures of the home. The staff team are positive in translating policy into practice and showed good knowledge of care principles, health and safety and safeguarding issues. This includes the management of finances within the service, where systems were directly observed to be transparent and open, with detailed records being maintained at all times. The service operates a quality assurance system that consists of surveys to relatives and discussions with people living in the home. The outcomes seek to improve the service and evidence was observed of the actions that the manager aims to improve to develop the service in response to a number of outcomes raised. This system could be further improved to show a clear plan of action and steps taken in each case to improve and resolve any issues raised. The document presented is also not user friendly. In addition the service operates an open door policy for relatives to contact the manager and discuss any views about the services delivery. There are also opportunities for people living at the home to attend ‘residents meetings’. The service responds to complaints and ensures that feedback is given to the complainant. The service does not manage finances on behalf of people living at the home. All charges for services such as chiropody and hairdressing are made through invoicing. Evidence of staff supervision with their line manager was seen in the staff personnel files sampled at this inspection. However it was noted that some staff had not obtained six supervision sessions in a year. It was also noted that some of these sessions were group supervisions. The service operates under its own health and safety policy and procedures that were available to guide staff. The training staff receive in health and safety issues such as food hygiene and moving and handling training supports these. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 27 The service held certificates in relation to the safe operation and maintenance of equipment according their legislative responsibilities. The certificates that demonstrated this were considered at this inspection and included Electrical installation, gas safety soundness test, lift maintenance, moving and handling hoists, portable appliance testing, fire extinguishers and emergency lights and fire alarms. The service carries out monthly visual check of the fire safety systems and there was a fire risk assessment in place. The records included the monitoring of staff attendance at fire drills. Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 28 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 3 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 X X 3 X 3 2 3 2 Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 29 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 OP19 Regulation 13 (4) Requirement All carpets must be fitted securely to the floor. To ensure that people are protected from the risk of tripping and falling. A pedal bin and food preparation table must be supplied. In order to minimise the risk of cross contamination and promote positive food hygiene and food handling practices. All internal doors must close securely and not be propped open by any objects other than those recommended by the fire authority. In order to ensure that people are kept safe at all times. Timescale for action 19/11/09 2. OP19 13 (4) 30/10/09 3. OP38 13 (4) 15/10/09 Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP7 OP7 Good Practice Recommendations The service should ensure that assessments are fully completed and that they are reflective of a persons cultural and diversity needs. The service should review the process for monitoring and reviewing of documentation regarding each individual to avoid repetition. The service should ensure where a risk assessment tool is used that determines an overall risk rating that this is assigned and appropriate actions implemented following completion. Consent to care plans forms and consent to medication administration forms should be signed if the service has implemented them. A pill counter should be purchased. All bottles, tubes and boxes of medicines should have a date of opening on them. All hand written entries on the Medication Administration Sheet must be double signed. The service should consider using memory boxes throughout the service for room recognition for people with dementia. The service should consider the replacement of furniture items in some of the bedrooms. Consideration should be given to the layout of the laundry facilities to promote good infection control practices. Staff should receive at least six one to one supervisions per year. 4. 5. 6. 7. 8. 9. 10. 11. OP7 OP9 OP9 OP9 OP19 OP19 OP26 OP36 Cleaveland Lodge DS0000017795.V377512.R01.S.doc Version 5.2 Page 31 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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