Inspection on 06/08/08 for Cleaveland Lodge

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Adequate service.

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 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 16/12/2008.

CARE HOMES FOR OLDER PEOPLE Cleaveland Lodge 151 Rowhedge Road Old Heath Colchester Essex CO2 8EJ Lead Inspector Sara Naylor-Wild Unannounced Inspection 6th August 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleaveland Lodge DS0000017795.V370197.R02.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.V370197.R02.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.V370197.R02.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) 3rd July 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.V370197.R02.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on the 6th and 13th August 2008. As part of the inspection we checked information received by Commission for Social Care Inspection (CSCI) since the last inspection in 27th July 2007, looking at records and documents at the care home and talking to the manager, Ms Asha Beefnah, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in May 2008 was considered as part of the inspection process and a tour of the premises was completed at the visit to the care home. The AQAA contained information about what they felt they did well. This information was brief and did not always tell us how the service was seeking to improve the outcomes for people living at the service, beyond their present provision. The manager assisted the inspector at the second site visit. Feedback on findings was given during the visit with the opportunity for discussion or clarification. We would like to thank the manager, the staff team, and people living at the service and their relatives for their help throughout the inspection process. What the service does well: The assessment documents used by the service provide opportunity for staff to gather a comprehensive level of information about people they are considering admitting to the home. The care planning documents provide staff with an indication of each person’s abilities and needs. They are written in a positive way to highlight what people can do for themselves. Medication administration was generally good with accurate records and evidence of staff adhering to good practice when giving medication to people living at the home. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 6 There are activities provided on a daily basis in the home that people can choose to join, although the opportunities for those people who were in advanced stages of dementia were not so well developed. The service has appointed an activities co-ordinator and provides equipment and resources for people who live at the home to use. The premises are maintained to a high standard and provide a welcoming, homely environment for people to live in. The staff group is relatively stable and there are sufficient numbers of staff for the service not to rely on agency staff. There is training and support for staff in carrying out their duties. The service listens to people through its complaints procedures and seeks to gather people’s views about their performance through a quality assurance system. The service is owned and managed by a family who have demonstrated a long commitment to the care and support of older people in a residential setting. What has improved since the last inspection? What they could do better: The development of assessment, care planning and risk assessment documentation requires attention to ensure that the information contained in them is consistent and provides sufficient information for staff to understand how to improve the quality of peoples daily lives. The way in which the day is organised must be regularly reviewed by staff to ensure they are carrying out their duties in a manner that achieves the best outcomes for people living at the service. Specifically the examples seen of staffs approach to mealtimes demonstrated a lack of awareness by staff in how their actions affect the people they support with cognitive impairments. The storage and management of controlled drugs must be addressed to ensure that the service is operating within the updated guidance and good practice from the Royal Pharmaceutical Society of Great Britain. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 7 The range of activities on offer and how people with cognitive impairments are engaged should be further developed. In particular staff need to gain skills in working with people with less social skills due to their dementias. Staff training should be broadened to introduce subjects that will support the staff in gaining more specialist skills in supporting people with dementias and develop the services quality approach to a specialist area of residential support. The quality assurance system should respond to all the feedback received from surveys. 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.V370197.R02.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.V370197.R02.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): 3, Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the home can generally be assured that the service will understand their needs prior to agreeing to their admission. EVIDENCE: The pre admission assessments of the people most recently admitted to the home were considered at this visit. The person’s file contained both the Social Services needs assessment known as a COM5 and the homes own admission document. The format of the home’s 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. As an Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 10 example under foot care the forms prompts ‘Foot care this should include any special risk i.e. diabetes should identify any professionals involved in the care of their feet’. The completed format provides the reader with a good level of information from which to determine if the home would be able to meet the person’s needs and if additional equipment would be required prior to admission. However in the sample seen the elements in risk management, mental health, social support, mobility, continence, nutrition, personal hygiene, memory and communication not been completed. The service states in its AQAA under the section ‘choice of home’ that they “Provide an excellent care package tailored to the individuals needs and requirements”. The statements are at odds with the incomplete assessment documentation and the quality of this was discussed with the manager in ensuring that the service sufficiently understands the way in which they may need to support the individual. Cleaveland Lodge DS0000017795.V370197.R02.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): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home can be assured that the staff will understand some of their needs, but cannot be confident that this is documented. EVIDENCE: The care planning documents of five people living at the service were looked at as part of the case tracking methodology used at the inspection. 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.V370197.R02.S.doc Version 5.2 Page 12 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. For example it stated in one persons plan under ‘sleeping and walking’, that the person generally has a good sleeping pattern and will sleep very well. But at times they tends to wander about their room or the corridors at night so will need to be observed closely. It said the support needed was in getting them ready; and under how staff should support it said; ‘xxx cannot get undressed and dressed into nightwear independently and will require assistance to do this. Going to bed - xxx will need the assistance of two staff to go to bed but they usually stick to their routine and goes to bed when ready. Waking - xxx wakes and gets out of bed when ready. Staff to observe as xxx is prone to falls.’ 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. In one plan sampled the instructions for ‘dementia’ state “due to the person’s dementia they sometimes claim people are out to get them and they see things, they can also become physically and verbally aggressive”. The stated goal was for staff to observe and reassure and under the ‘rational for action’ staff were instructed to report any changes in mood and evaluation. 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 for example staff should check on the person at night and what steps are taken to reduce the risk of them falling at night, or what approach may reduce the persons anxiety and aggression. However discussions with the manager indicated that there was more information known to the staff team such as their understanding that if they turn on the radio in the morning and allow xxx time to ‘come to’ with the music they are calmer and more settled. This was not identified in the care plan but the manager felt that this was shared verbally with staff. 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. In some care plans the MUST tool had not been completed or updated. The manager stated that the member of staff trained in the application of the tool had left the home and although a new member of staff had been trained in the tool they had not been able to “get to grips “ with it yet and the manager intended to work with them further on this. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 13 Four of the five care plans sampled had no significant concerns relating to the risks presented to the individual’s mobility. The records for accidents for one person record that they suffered 14 falls between September 2007 and December 2007 of which 12 were at night in their bedroom. Four further falls were recorded from January 2008 to the day of the inspection. In this one example, it was highlighted in the risk assessments for falls, that there were records not completed with sufficient information to understand what strategies had been considered, and the specific steps taken to reduce the risks. They stated that the person has a risk of wandering at night and a second assessment relating to falls stated they had suffered from several falls and were at a high risk of further falls. The staff were advised to be vigilant and observe regularly as the person liked to move furniture around at night. The night care record for the same person stated that a crash mat was in place to protect them from falls from their bed although this is not included in the risk assessment information and appeared to be at odds with the statement about their getting up at night and moving around, which would make this an unsuitable piece of equipment to use. Overall the risk assessment process requires a better understanding by staff completing them to ensure they answer and document the five recommended steps of risk assessment. The staff team were responsible for the completion of daily records. These were generally statements about the how settled the person had been and if there had been visits from health professionals or families. They did not reflect the plan of care or indicate if the way in which staff were supporting the person was beneficial or otherwise. This information is vital when carrying out reviews of peoples care plans to ensure that the action taken has been successful or otherwise in addressing their needs. Records were maintained to monitor people’s health and wellbeing and these included issues such as weight, nutritional intake and skin integrity. There were records that confirmed the outcomes of health professionals visits including chiropodist, doctors and District nurses. The information from these visits was updated in care plans and evidence was seen in daily records of the discussions that had taken place with the district nurse in relation to one person’s pressure care and the instructions that followed for staff. Overall the information gathered in these records enables the service to understand how people’s health and wellbeing are progressing and highlight areas of concern. The services AQAA stated in the section Health and Personal Care under the heading of how we have improved in the last 12 months “Using tools such as Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 14 M.U.S.T and Tissue viability etc. To ensure all care aspects are met and monitored for the individual. Risk assessments are also more individual based and are reviewed monthly.” Medication administration was considered at this visit. The administration of medication for the lunchtime period was observed and the senior staff responsible carried out this task with due care and attention. Medication is dispensed in monitored dosage packs from the pharmacist. The medication and records for five residents were inspected. All medication was present as prescribed and accurately recorded. Medication administration records (MAR) were well recorded and no gaps were found in the record. The staff member spoken with was confident about their duty in this area and spoke with authority about their responsibilities. Discussions took place with the senior staff and manager in respect of the procedures for monitoring medication records. They advised that the night seniors review the previous days MAR sheets and advise where omissions have been made so that the member of staff responsible could fill the gap. Advice was given to review this practice to ensure that the record gives clear information. Discussions were also held with the manager about the storage and recording of Controlled drugs. The manager reported that they were not aware of anyone living at the home being prescribed controlled drugs at that time. However some people were prescribed Temazepam that was dispensed according to the prescribing instructions and recorded on the MAR sheet. Their pharmacist had advised the manager that these were not on the controlled drugs list, however, The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 made changes that affect care homes. This included the requirement to store Temazepam as a controlled drug and as a good practice recommendation to record its administration in the controlled drugs record. The manager advised that the service was prepared to administer controlled drugs with a small metal locked container that would be stored within the medication trolley and a controlled drugs record book. They were advised that this was not appropriate storage and to review the guidance provided by the CSCI in respect of the correct type of storage for these medications. Following complaints received about letters sent to relatives asking about their relation’s end of life wishes the service does not collect this information for care planning. The manager stated that where people expressed a wish this was noted, but otherwise families were only asked about this area of care when it was required. Although this is always a difficult and sensitive subject it is acknowledged good practice that people are consulted about their wishes at the end of life. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 15 The manager was advised to gain guidance and support from specialists such as the National Council for Palliative Care who have published a introductory guide to end of life care in care homes. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 16 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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home can be confident that there are opportunities to participate in activities. They cannot however be assured that these will be tailored to meet their abilities, needs and expectations. EVIDENCE: The service operates a weekly activity programme that is publicised in prominent positions around the home. The activities are provided in two blocks during the day between 10 and 11 am they offered jigsaws, art and crafts, board games, dominoes and cards. In the afternoons, between 2pm and 4pm they offer weekly outside entertainment, films, ball games, skittles, chair exercises, bingo and quizzes. The service employs an activities co-ordinator who works from 09:00 hrs to 14:00 hrs, three days a week on Mondays, Wednesdays and Fridays. In between these periods care staff carry out activities during the allotted times. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 17 The service aims to provide outings at regular intervals using a local mini local minim bus company. The co-ordinator maintains records for each person’s participation in the activities. The records relating to the people whose care was case tracked during the inspection were considered. These were varied in how much people were engaged in activities. For some people their record stated only that they were calm and the locality in the home they had spent time in. However others record a greater level of detail about activities they had joined in with. The care plans for the people with less engagement also contained less detail about their social needs and outlets, than those who had a fuller programme of activities. The services AQAA states in the section what we could do better in daily lives and activities “Activities – It is our aim at Cleaveland Lodge to provide a wider range of activities to Service Users and to encourage Service Users to participate on a greater level”. This was discussed with the manager who agreed that the provision of activities was still a developing area of the services support. She said there had been efforts made to identify training and guidance that would support staff in carrying out activities, but that the people living at the home had not responded to the initiatives that were tried as a result. People spoken to during the inspection gave varied responses to activities. A person living at the home, said they did not like doing the puzzle they had been provided with, whilst another person told us that they had enjoyed the colouring in they were doing so much they did not want to stop. A visitor told us that they felt the service did not excel at activities, particularly for those people in the advanced stages of their dementia. The service’s own Quality Assurance survey of people living at the home and their supporters had been carried out earlier in 2008. The responses to the questions about activities in the home was overall very positive with 33 people of the 48 returned feeling the activities were good, and 3 stating they found them to be excellent. A further 12 said they were fair. Of the 32 relatives responses to questions on activities 1 said they were excellent, 18 felt they were good, 10 thought they were fair and three felt the provision was poor. Overall this is an encouraging response to activities and provides the service with indications of how they can seek to improve the outcomes of this element of the satisfaction survey. Although the services AQAA states “Service Users at Cleaveland Lodge are able to have visitors at any reasonable time and can choose whom they see and do not see. Communal areas are available to all visitors as well as the service user’s private bedroom if they so wish”; there were details of the services visiting times between 09.45 – 11.30 hours, 14.00 – 16.30 hours and 18.00 to 19.00 hours. The manager stated that these times were not intended to be restrictive to visitors and were for guidance only. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 18 Visitors spoken with felt able to visit at any time and said they were always made to feel welcome, some visiting on a daily basis. They told us “the staff are very cheerful and friendly and are always doing the best they can.” The menu is planned with the known preferences of the people living at the home, and provided a choice of varied nutritious meals. The menu choices were advertised in the dining rooms and people were reminded of the choices at the meal. 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. During the two inspection visits to the home the midday meal was observed. On the first occasion the staff’s organisation of taking people to the toilet and bringing people to the meal table to commence the meal was very chaotic, mainly due to the absence of staff in the dining rooms to support people who were unsettled. It can be common for people with cognitive impairments to be unable to recognise the purpose of the activity such as mealtimes without such visual clues as a plate of food in front of them, and often results in people being restless and unable to settle, becoming agitated and causing distress to others. On this occasion several people were repeatedly brought back to the table by staff and in their absence one person grabbed other peoples clothing and moved furnishings in order to get away from the table, causing distress and pain. If the aim of a meal is for people to enjoy a meal in a relaxed atmosphere conducive with good digestion then this was not achieved at this meal. The situation was quickly settled once staff were in attendance and they reacted to the situation by providing support to the person who was agitated, allowing them to move to a position they were more comfortable in. The second day’s meal was observed to be calm and well organised, with at least one member of staff remaining in the dining room to support people sat at the tables, and people not being brought to the table too soon before the meal. The whole atmosphere was more social and relaxed with people either sitting quietly or chatting and joking as staff replenished drinks and set the table. The difference in the way in which the meal was handled and observations of the way in which this affected the people living at the home was discussed with the manager. The manager stated that the circumstances of the first visit were not usual for the home. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 19 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): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living at the service can be assured that the staff understands how to listen to them and protect them from abuse. They cannot be assured that the appropriate steps are taken to prevent staff accused of abuse from working with vulnerable people in the future. EVIDENCE: The service has a complaints policy that includes details of the complaints response time and the recording of all complaints in the complaint book. The service previously maintained the log in a folder with forms that asked for details of the complaint the action taken to investigate and the response made. These were kept in the key workers files to prompt their completion when staff received complaints. There were no records of entries using this form made since the last inspection. There was also a hardback book titled complaints log being completed and this contained records of two complaints received since January 2008. Both the complaints were from peoples relatives one relating to the inappropriate use of a commode and another relating to the replacement of a light bulb that had been broken for two weeks. The record indicated that the issues had been dealt with, but not the details about the services investigation into the reason the issue had arisen. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 20 A further complaint that had been received by the Commission from a family member in relation to the falls suffered by their relative living at the home and their concerns about the services falls prevention action. This was passed to the service for a response under their complaints policy. The issue had been responded to and the complainant informed the Commission of their satisfaction with the outcome. There was not a record of the complaint in the services complaints log. The manager stated that they believed, as they had not received the complaint directly the complaint had been recorded using the Commissions complaints processes, and the service was not required to log it. They were advised that any complaint received by the service from any source should be recorded and responded to according to their own complaints policy and procedures. The service has a safeguarding policy and procedure and a staff whistle blowing policy. This detailed the way in which the service meets its responsibilities to protect and report allegations of abuse in accordance with local guidance and the No Secrets publication. The service has reported two Safeguarding alerts to the local authority in relation to the behaviour of staff. In the first referral the safeguarding strategy meeting convened upheld the allegation and the service sought to dismiss the member of staff concerned. However they person resigned their position before this was carried out. The manager and proprietor stated that the home had not referred the staff member to the Department of Health Protection of Vulnerable Adults (POVA) list, as they believed this was carried out as part of the strategy teams conclusions. This is not the case and in fact the only agency that can make a referral to the POVA list as defined by the Care Standards Act 2000 are the “providers of care”. The manager was directed to the guidance available from the Department of Health website, and ensure that the referral was made as soon as possible. The second referral had been investigated under direction of the strategy panel by the service and had not been substantiated. However, disciplinary measures had been taken with the staff member and as a result they were subject to a programme of enhanced line management supervision. The written records of this were not available at the time of the inspection and diarised dates had not been set out for the regular meetings. The proprietor said that there had been a significant event requiring the absence of family members from the home and this had delayed the recording of these processes but that supervision of the person had commenced. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 21 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service can enjoy a pleasant environment that meets their needs. 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 high standard both internally and externally and there was extensive evidence of redecoration and replacement of furnishings and fittings as required. The building has been progressively altered over the period the proprietors have owned the home, with additional wings being added to the main building. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 22 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. During the visits people living at the service were observed walking about the home opening doors and entering and leaving bedrooms, apparently searching. The way in which people’s independence was supported by the décor and signage used in the home was discussed with the manager during the visit. They stated that they had considered the use of colours and other signs in the home but had wanted the home to retain a homely appearance and wanted to steer away from a multicoloured home. They said they had found that some people used the pictures on bedroom doors as a means of identifying their own room. There has been extensive research into the way people with cognitive impairments can be supported to retain greater independence through the use of ‘signposts’ using colour, texture and pictures. Whilst retaining a homely environment the use of these tools provides an ‘enabling’ environment that supports peoples sense of wellbeing. The way in which people are supported by the environment requires some consideration as part of the services quality assurance process. The plans outlined in the last inspection report for a residents kitchen and additional laundry facilities had been changed and the kitchen had been altered into a dining room whilst the laundry was awaiting refurbishment at the time of the inspection, although there was sufficient equipment for the needs of people living at the home in place, the layout 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’. One of the smaller lounge/diners used by people living at the home, also housed a large fridge freezer. Neither function was locked and the contents on the day of inspection were mainly milk and the manager stated that staff also stored their lunches in this fridge. The proprietor advised that there was a staff facility on the first floor of the home, but that staff preferred not to use this and instead tended to stay in the communal areas of the home. The manager was asked to review the appropriateness of the placement of this equipment in the communal space of people living at the service. 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 home although the staff toilet did not have any soap. Cleaveland Lodge DS0000017795.V370197.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available 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. Specialist training in dementia care could further improve the level of support they receive. EVIDENCE: There were 52 people living at the home at the time of the inspection and the staff rota demonstrated that the service was aiming to maintain 7 care staff on duty during the waking day with the manager and activities co-ordinator in addition to these numbers. We were advised that the care manager and the provider also assist in meeting people’s needs, although they were not reflected in the overall numbers on the rota. Two catering staff, one laundry staff and three domestic staff on duty also supported the home each day. The staff were observed during the visit and did not appear to be rushed or unable to spend suitable time with people needing their support. The service does not use agency staff. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 24 The service’s AQAA stated in relation to staffing “The numbers of staff at any one shift is calculated using a formula devised to take into account the number of service users, their dependency and needs.” People who were spoken to during the inspection felt the staff did not hurry them and that they were patient when they provided support. The files of five staff were considered at this visit to understand how the service recruited, trained and supervised staff. The service states that of the 51 care staff, 65 of staff hold NVQ level 2 or above with a further 30 undertaking the course. Documents seen on staff personnel files supported a robust method of recruitment. These included a full application form, two references, proof of identity, work permits where required and checks against the Criminal Records Bureau (CRB) and Department of Health Protection of Vulnerable Adults (POVA) list. The manager maintains a dairy of all training booked for the current year. This included items in response to health and safety legislation and those items staff have requested. The subjects included Moving and handling, dementia, first aid, food hygiene, Medicines for senior staff, first aid and Diabetes care. The manager had made an application to the Essex County Council training grant and had successfully secured funds. The training staff received in dementia care as described by the manager and staff was aimed at an introductory level that supported staff in understanding the types of diagnosed dementia and typical behaviours associated with the disease. The service did not include any ongoing developments in dementia training in it’s annual programme such as studying of therapeutic techniques that staff could use when supporting people with dementia, diet and nutrition and dementia care, activities for people with dementia, and palliative care for people with dementia. This is an area that the service should consider in its future quality assurance planning. With the government holding national consultation on the future of care for people with dementia and organisations such as the Alzheimer’s Society calling for mandatory training in dementia care there is an increasing expectation of care homes that support people with dementias to develop the quality of their specialist approach. Cleaveland Lodge DS0000017795.V370197.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 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. People living at the home can be assured that an experienced management team supports the home. EVIDENCE: The manager Asha Beefnah had taken over the manager post from Mrs. Melanie Beefnah this year and had been registered by the Commission shortly before the inspection took place. Asha Beefnah has worked for 10 years in care settings, and has qualifications in GNVQ health and social care, train the trainer and was undertaking her NVQ Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 26 level 4 Registered Managers Award and holds a BA (Hons) in Hospitality and Business Management. Mrs. Melanie Beefnah continues to be heavily involved with the service and remains the registered proprietor. Mrs Beefnah’s son also works at the home and is a member of the management team. The service operates a quality assurance system that consists of surveys to relatives and discussions with people living in the home. The feedback from these was collated into an audited report and the service published this and its responses to the areas for improvement. This year’s audit received 48 responses from people living at the home and 32 responses from family members. The questionnaire asked for people’s views in the quality of care, friendliness of staff, cleanliness of the home, décor and ambiance, activities, meals, response to complaints and overall impression of the home. They received a high proportion of feedback with between 68 and 47 of the 48 people who live at the home who responded, expressing good outcomes and between 37 and 6 stating excellent outcomes across the questionnaire; Relative’s returns varied between 62.5 and 50 stating there were good outcomes and between 50 and 3 stating that they found the outcomes excellent. People living at the home identified in their feedback some dissatisfaction with between 4 and 2 rating poor and 25 and 4 rating fair in outcomes relating to the quality of care, friendliness of staff, cleanliness of the home, the décor and ambiance, activities, meals, response to complaints and overall impressions of the home. Visitor’s feedback identified some dissatisfaction with between 9 and 3 rating poor and between 31 and 6 rating fair to quality of staff, cleanliness of home, social activities, presentation of meals, response to complaints and overall impressions of the home. The services response identified action taken in response to the relative’s feedback about activities and complaints, but did not refer to how the service proposed to address all the areas such as friendliness of staff, cleanliness of the home, the décor, ambiance and meals in which an outcome of less than good was returned. 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. Where appropriate advocates have been used in reviews and when dealing with complaints. The service does not manage any monies on behalf of people living at the home. All charges for services (chiropody, hairdressing etc.) were made through invoicing. Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 27 Evidence of Staff supervision with their line manager was seen in the staff personnel files sampled at this inspection. There were some shortfalls in the frequency and consistency of supervision sessions with examples seen of only two sessions in 2008 for one person whilst others had more than three in the same period. The arrangements for supervision are that the manager supervises senior care staff that in turn supervises the rest of the care staff team. 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. 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.V370197.R02.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X N/A 2 X X Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 29 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 OP9 Regulation 13(2) Requirement Timescale for action 31/10/08 2. OP12 16(2)(m) & 16(2)(n) To ensure residents are given medication as prescribed: 1. Medication policies and procedures must be reviewed to provide more detail for controlled drugs in accordance with The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 2. A CD drug register must be provided. 30/09/08 1.More social activities and outings must be provided by skilled staff that ensures residents are stimulated and their lives are enhanced. 2. Records must demonstrate how the service supports people’s choice and participation in activity. 3. OP18 Care Standard s Act 2000 Part VII, 82. (1)(2) and (3) The registered persons must ensure that staff that are the subject of abuse allegations are referred to the Department of Health’s Protection of Vulnerable Adults (POVA) list. 30/09/08 Cleaveland Lodge DS0000017795.V370197.R02.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. Refer to Standard OP7 Good Practice Recommendations Care plans should provide sufficient detailed information to support consistency in the quality of staffs support to people living at the home. They should reflect all the information known about the person and how best to meet their needs. Assessments that support individual’s health and wellbeing such as the Malnutrition Universal Screening Tool (MUST) should be carried out and monitored to optimise their health. The way in which people wish to be supported at the end of their life should be discussed and documented to ensure continuity in the quality of their support at the palliative stage of their life. When carrying out their duties as part of the daily routine of the home, staff should consider how their actions impact on the wellbeing of people living at the home. Specific examples include the preparations for mealtimes. All complaints received by the service in any format from any source should be documented and responded to in accordance with their complaints policy. Staff training should reflect the skills required to meet the assessed needs of people living at the service. The development a specialist quality delivery to people living there should be supported by the expansion of the staff training programme. Staff supervision should be consistently provided to ensure they receive regular feedback and support in the development of their roles. 2. OP8 3. OP11 4. OP12 5. 6. OP16 OP30 7. OP36 Cleaveland Lodge DS0000017795.V370197.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V370197.R02.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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