Inspection on 05/12/06 for Cleaveland Lodge

This inspection was carried out on 5th December 2006.

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

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

Other inspections for this house

Cleaveland Lodge 04/09/09

Cleaveland Lodge 06/08/08

Cleaveland Lodge 03/07/07

Cleaveland Lodge 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 Tim Thornton-Jones Key Unannounced Inspection 5th December 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleaveland Lodge DS0000017795.V317484.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.V317484.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 (6), Old age, registration, with number not falling within any other category (54) of places Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 54 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 6 persons) The external grounds to the rear of the premises are to be suitably landscaped within six months from 1 December 2005 16th March 2006 Date of last inspection Brief Description of the Service: Cleaveland Lodge is a large, family house that has been extended and improved over recent years to form the present accommodation, which is offered on the ground and first floor. There is a passenger lift to enable first floor access. In addition to the former extension to the premises, the home has recently been further extended to the rear, increasing the registered beds to 54, six of which are registered to accommodate service users who require care by way of a dementia. The service offered is to create a homely and comfortable environment for older people over the age of 65 years who require, or choose to live within, a care setting by way of their old age and associated needs. The Statement of Purpose states that the home will accommodate service users, within the registration category, who wish to make Cleaveland Lodge a home for life, providing the service can continue to discharge its duty of care to the individual, with or without community healthcare support. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The weekly fees for this service were confirmed as between £360 and £420 per week. The overall outcome of this report was good with areas of development noted including quality assurance and care management. The overall environment was considered to be better than the national minimum requirements and was rated as excellent following the comments received by staff, visitors and service users. Some areas remain in development and these were focussed within the staffing and lifestyle outcome groups. As part of this inspection some additional data was collected as part of a wider evaluation of older person services. This was undertaken as part of a ‘case tracking’ approach of three service users at random. Each of the three service users was asked pre-determined questions relating to four key areas. Area one included information about changes to the cost of care and receipt of the service users guide. The outcome of this group was that none of the service users had recollection of having received a service users guide although copies were available on individual files. None of the service users were aware of matter associated with the cost of their care or of changes as their relatives tended to manage these on their behalf. Area two included information about the contractual arrangements. Whilst copies of contracts were available for the three people concerned, none of the service users were aware of any contractual matters, stating that relatives took care of those matters for them. Area three was about assessment of need. All three sampled files showed that a needs assessment had been undertaken either by the local authority or by the Manager prior to the service user residing at the home. None of the three service users, when asked, had clear recollection of the assessment process. None of the three service users were able to say, with any accuracy, how long they had lived at the home. Two stated that they recalled being asked lots of questions but was too long ago to remember. Area four related to complaints. None of the service users stated they had a copy of the complaint procedure (although a copy was incorporated within the service users guide) but all stated they were confident to make a complaint and to whom it should be made. All stated they would discuss their concerns Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 6 with relatives in the first instant unless the matter was relatively minor and then they would speck to individual staff members. Overall, based upon discussion with service users, staff and relatives, observation, reviewing of records and procedures the care outcomes are good. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the service approach to pre-admission assessment and transition arrangements. EVIDENCE: Three care plans were examined at random to review the way in which the home had undertaken the admission process for the individual concerned. The plans showed that in all instances a pre-admission assessment had been undertaken and was in place, in this instance two persons were referred by the local authority and one, a private referral. The latter example had an assessment undertaken by the home covering social history, preferences, needs and other supporting information on which to formulate an initial plan of care. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 9 The home does offer a respite service from time to time when suitable single bedrooms become available. At the time of this visit the home had no empty rooms. The home does not offer intermediate care services. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • • Service users benefit from Service users benefit from Service users benefit from prescribed medicines. Service users benefit from privacy and dignity. the care plan arrangements. arrangements to meet healthcare support. the homes arrangements to administer the homes practices to ensure service users EVIDENCE: Based upon a sample of three care plans it was noted that the overall structure and organisation of planning across the sample, was similar. This has the advantage of staff becoming familiar with the documents and therefore able to navigate them as efficiently as possible, particularly given the relatively high number of service users accommodated. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 11 Each care plan had a number of risk assessments in place covering a wide range of matters. In some it could be argued that the extent and range of risk assessments was possibly too comprehensive and that it would be sensible to include those assessments that address presenting and known risks. Assessment practice in this way would focus on those areas of support that identify ways in which the individual can be assisted to overcome the risk if possible. The construction of the plan indicates that the service user and/or their representative were involved in the process, for example the plan included personal details associated with preferences and choices, however none of the plans sampled had been signed by the service user or representative. A daily written narrative is produced within the ongoing record, which if very brief, however, the home now has 54 service users and detailed notes on daily basis for all service users is not considered realistic. The Manager advised that more comprehensive notes are maintained for service users who are being monitored specifically due to a particular frailty or illness. Each service user also has a monthly review summary, which is more comprehensive. It was pleasing to note that the care plans and review data was written in plain English. As part of the monthly review, the plan is updated to ensure that primary healthcare screening and routine appointments are planned for. This includes appointments for dentist, Chiropody, Optician etc. Those service users at risk of developing pressure areas were being monitored and are supported by visiting healthcare professionals. At the time of this report few service users required this type of support although the community nursing services were visiting the home twice weekly. A separate record is maintained for this and it is advised that this record form part of the care plan in a way that is more integral to the process. The review process updates the record, for example if a service user had not seen a healthcare professional during the preceding month, the review would reflect this. If the person had seen the GP, the record would have been updated at the time. Consent by the service user to the home administering medicines on their behalf was on the sampled files. A list of all current prescribed medication was detailed within the plan. The specific record has a section for what the medicine is for and the known side effects for staff to become alert to the risks. The care plan is divided into 13 areas of need and each section sub divided into ‘summary’, ‘preferences’ and ‘support requirements’. This latter section Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 12 gives a good explanation to the carer on the preferred way in which the care is to be delivered. This ensures continuity for the service user and a consistent methodology for the staff member. The Key-worker system was being reviewed at the time of inspection to ensure that appropriate support is understood and co-ordinated at the ‘hands on’ point of service. Other records are held within the plan such as weight and, where necessary, fluid intake and blood pressure. Blood pressure readings are taken where appropriate, following consent by the service user, using an electronic wrist strap automatic device. The Statement of Purpose makes it clear that the home does not provide nursing care although for some service users who are prescribed medicines to control blood pressure, this routine periodic check is a sensible precaution. A variety of equipment was in use for service users. These included hoists, slide sheets, frames and wheelchairs, and other moving and handling aids. Service users are assessed following any falls. This is undertaken in collaboration with the GP, although this could be further developed by the use of a monitoring tool within the plan of care. The Inspector discussed this with the Manager. Medicines administered via prescription are of a monitored dosage system type. This has recently been reviewed by the home as the internal checking and quality system identified some errors on the part of the supplier. The manager advised the Inspector that quality monitoring is to continue to ensure the safety of service users. The medicine storage was secure and well maintained. The medicine administration record was also well maintained. Staff who administer medicines are trained by the pharmacy supplier. Three service users were spoken with at some length, one service user had relatives visiting at the time. All stated that the care staff were kind and supportive and that their life at the home was comfortable. All three commented particularly on their bedroom being well furnished and decorated. All stated the provision of food was good being varied and of good portion. The relatives spoken with supported the view that the home was comfortable and the staff supportive although did comment on the limited opportunity for activities (See Quality Assurance). Staff were observed to communicate appropriately with service users and of the service users spoken with all stated the staff to be kind and friendly. Staff Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 13 were observed by the Inspector to communicate in a professional manner using appropriate tone, volume and language. Cleaveland Lodge DS0000017795.V317484.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): Standards 12 to 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • • Service users do not fully benefit from planned social and leisure arrangements. Service users do not fully benefit from the homes arrangements for visiting. (See recommendations) Service users mainly benefit from the homes approach to helping service users exercise choice and control over their lives. Service users benefit from the homes arrangements for catering EVIDENCE: The home no longer employs a specific activities co-ordinator although one person (carer) on duty is highlighted on the rota each day to lead and coordinate activities. In view of the number of service users accommodated and the diverse social needs to be met, this level of resource allocation will not meet requirements. At the time of inspection no log is kept in relation to the activities that were described by staff as including Bingo, carpet bowls, cards Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 15 etc. The inspector recommended to the manager that this aspect of the homes activities be recorded in a more reliable way. This is particularly important for service users who are mentally frail. The homes quality assurance system highlighted a need to improve this are of the homes service. See Quality Assurance. The home has adopted an approach that requests limiting visitors to the home during certain times, which has previously been the subject of a concern expressed by a relative to the home. The Manager stated that as a result of a service user meeting and from various comments received from service users, the manager considered that, as a general rule, visitors should be requested to visit at times other than meal times (unless sharing a meal with a relative, as observed on the day of inspection) and avoid visits after 8.30 in the evening as service users often have baths and like to relax wearing night attire. The Manager stated that individual arrangements would be made in particular circumstances, for example when the service user was unwell or where relatives were demonstrably unable to visit at any other time. This is a difficult balance for the home to achieve and the recommendation is that the homes policy be clearly stated within the Statement of Purpose. The home does not hold service users cash in safe custody and payments for any additional services, such as hairdressing, chiropody etc, are requested by the home directly by relatives, although some service users do hold some personal money themselves. The Manager has continued to develop various areas of the home operation and one such area is the monitoring of service users nutrition intake. A revised and informative recording tool had been introduced during the week of the inspection visit that details what meals and snacks have been taken by each service user and include quantities. The manager uses this information to ensure that changes in diet and apatite are regularly monitored. As the system had only recently been introduced it was not sufficient to evaluate how useful the approach had been although initial use of the tool appeared informative. Three service users were spoken with at some length. One, who was being visited by relatives were unable to clearly express their life at the home although the person’s visitors were able to assist the person with this. All service users spoken with expressed satisfaction with the care they receive and the way in which care staff support them. All stated that carers were kind and thoughtful and supported them in the way they wanted. All service users stated that the food provided was enjoyed and was varied. The mid-day meal was observed and appeared to be well presented and of good quality and quantity. Cleaveland Lodge DS0000017795.V317484.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users benefit from the service complaint and safeguarding adult’s procedures. EVIDENCE: The home has a complaint procedure, which sets out the homes role and time scales of responding to concerns. The home has investigated one formal complaint. This was reviewed at this inspection. The home has referred the matter to an external source to ensure objectivity. The Manager considers the matter has now been resolved. The home has made one referral under the safeguarding adults process and this involved a multi-disciplinary approach. The matter was concluded in a satisfactory way although there was no specific outcome. The role of the home in both of these matters was reviewed and found to be co-operative and professional. The Manager advised that one informal matter of concern had been dealt with directly with the person who raised them and was resolved at that point. One further matter of complaint was made directly to the home by a relative and the home have responded although the matter had not been concluded at the time of the inspection visit. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 17 The home has a copy of the local authority safeguarding adult’s policy and also has a whistle blowing policy and procedure. (See staff training). Cleaveland Lodge DS0000017795.V317484.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): Standards 19, 20, 21, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. • Service users benefit from a homely, comfortable, well decorated, furnished and safe environment to an exceptional standard. EVIDENCE: Since the previous inspection the grounds to the rear of the home have been landscaped and a secure fence installed to enable service users to use the area without the risk of exiting the site inadvertently. The centre of the home is a large and attractive courtyard area with seating. Whist service users rarely use this at present due to the inclement weather, Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 19 the area is particularly suitable for those service users who are mentally frail and who benefit from the freedom of use without close supervision. The premises have been refurbished and decorated to a very good standard. All service users spoken with commented favourably upon the comfortable surroundings. All of the communal areas were visited and some bedrooms were viewed with permission from service users. All of the areas were clean, well maintained, homely and comfortable. In view of the number of services users accommodated and taking into consideration the presenting needs and frailty of some persons accommodated, the environment was excellent. The whole home was clean and there were no odours detected anywhere. All service users and visitors spoken with commented upon the quality of the environment. The home was accommodating 54 service users although the design of the home is such that the appearance is of a fewer number. There are various communal options available. Care of Substances Hazardous to Health (COSHH) arrangements were in place. Cleaveland Lodge DS0000017795.V317484.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): Standards 27 to 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. • • • • Service users do not yet fully benefit from care staff having been trained in all the necessary areas to support their known needs. Service users do not yet benefit from the required proportion of staff qualified to NVQ level 2 or above. Service users benefit from the homes recruitment practice. Service users do not yet fully benefit from the homes approach to training and induction. EVIDENCE: Part of the inspection took opportunity to discreetly observe staff supporting service users. Several service users are becoming mentally frail and six places are reserved for people who have a dementia. A number of staff had received training in the care of people who present care needs because of mental frailty and from the Inspectors observation, staff supported service users appropriately. The language used, tone and volume were observed to be appropriate, although some staff commented that a small proportion of staff recruited from overseas were less confident in expression and language. This was discussed with the manager, who acknowledged this and stated the home Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 21 were supporting two carers whose English was developing, although confirmed the two carers in questions were very good, qualified carers. The manager will need to ensure that the carers whose first language is not English are able to communicate and understand expressed needs of service users. The Manager stated that at present, the staff in question work mainly during non-waking hours with English speaking staff to minimise the impact of the language issues whilst providing opportunity for communication development. Three staff files were examined in relation to recruitment, induction, training and supervision. Overall these were satisfactory although could be better organised to access information. The recruitment practice for all three staff was in accordance with regulatory requirements including references and a Criminal Record Bureau (CRB) certificate. Supervision for staff was taking place to a good standard of practice although the frequency was not reflective of the requirement specified within National Minimum Standards for this type of service. The Manager advised that a number of service users had been admitted since the previous inspection and it had been necessary to recruit a number of care staff, now thirty nine in total, and that it had not been possible to ensure that a high number of those recruited were in possession of NVQ2 and therefore the home will need to include the new staff on the training and development approach. On this basis less than 50 of the current total number of care staff have attained NVQ level 2 or above although some staff, sixteen at the time of this inspection, do possess this, or similar qualifications. Staff recruitment was reviewed. The home uses a method recommended by the Department of Health to calculate the number of staff required to support service users appropriately. The assessment indicated that 1179.58 care hours were required. Staff deployment records sampled indicated that 1365.00 hours were being deployed. In addition to care staff the manager employs two deputy managers and support staff such as cooks and housekeepers. The staff training and development system continues to develop although no carers were currently following the ‘Skills for Care’ induction system. The Manager is recommended to identify the number of staff requiring this approach and seek further information to ensure all new staff can be inducted to the required programme. Various training has been undertaken by carers since the previous inspection including operational skills such as moving and handling, and health and safety related training together with practice courses such as dementia care. The Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 22 training schedule showed that every month, staff attend training and development opportunities, which is positive. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • • Service users mainly benefit from the home being managed by experienced and qualified management team. Service users benefit from the homes approach to quality assurance and monitoring. Service users mainly benefit from the homes arrangements for health and safety systems checks. EVIDENCE: Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 24 The Manager, Mrs M Beefnah, has an extensive experience of managing services for older people within a residential setting. The management structure has been developed to form a three-person team, with Mrs Beefnah having two deputy managers who take specific responsibilities for parts of the homes day to day management. Mrs Beefnah has yet to complete an NVQ in care and management to level 4, however, both deputy managers have this qualification. Mrs Beefnah stated that she intends to now restructure the management further and to separate the management of the business from the day to day care delivery to improve performance. This will require Mrs Beefnah to nominate a person to be registered in respect of the daily management, which is understood to be imminent. The arrangements were discussed with the Inspector. The quality assurance system was reviewed. Questionnaires have been designed and provided for both service users and/or their representatives to complete. The results of the questionnaires have been analysed and the outcome has been considered in terms of an action plan. One of the main issues was the need to develop the homes social and activities for service users. The responding plan has been to design a further questionnaire specifically regarding activities to ensure that the provision has been subject to consultation with stakeholders. An activity log has also been commenced since the results indicated a need to develop this area of the home. The evidence seen provides a clear indication of service users consultation, collection and analysis of data, together with a resulting plan of action. This shows the basis of a quality assurance and monitoring approach. The homes records relating to health and safety matters were sampled. In addition to the maintenance of a COSHH register, the home maintains various safety checks to the fire alarm system, emergency lighting system, portable electrical appliances and gas safety. The dates on which checks were made to these systems are as follows: • • • • • Engineers report on fire extinguishers – March 2006. Emergency Lighting check – 27.10.06. Fire alarm system check – 15.8.06. (see below) Portable appliance check – 04.8.06. Gas safety check – 30.11.06. The last visit by the Environmental Health Officer was recorded as 16.06.06. The periodic checks of the fire alarm system is recommended to be more frequent than at present. The manager was advised to seek advice from the engineer who checks the system for recommended frequency. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 X X 4 X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16(2)(n). Timescale for action The Registered Person must 31/01/07 ensure that an appropriate and suitable range of activities are offered to service users to meet social and emotional needs and preferences. The Registered Person must 31/03/07 ensure that an adequate proportion of care staff are suitably trained to NVQ level 2. This is a repeat requirement to have been achieved by 30/07/06. The Registered Person must 28/02/07 ensure that induction arrangements for staff are in accordance with Skills for Care National Occupational Standards for care homes. Requirement 2. OP28 18(1)(a). 3 OP30 18(1)(c)(i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000017795.V317484.R01.S.doc Version 5.2 Page 27 Cleaveland Lodge 1. 2. Standard OP31 OP13 It is recommended the Registered Person ensure that suitable training to NVQ level 4 in both care and management, or equivalent, is completed. It is recommended that the visiting arrangements of the home be made clearer to ensure that relatives and visitors fully understand the homes policy. Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Cleaveland Lodge DS0000017795.V317484.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!