Inspection on 24/11/06 for Cleeve Lodge

This inspection was carried out on 24th November 2006.

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

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

Other inspections for this house

Cleeve Lodge 29/10/07

Cleeve Lodge 30/12/05

Cleeve Lodge 29/09/04

Cleeve Lodge 20/04/04

Cleeve Lodge 12/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cleeve Lodge 11 Elmhurst Lane Goring On Thames Reading Berkshire RG8 9BN Lead Inspector Delia Styles Unannounced Inspection 24th November 2006 10:45 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 Cleeve Lodge DS0000013073.V317957.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. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Lodge Address 11 Elmhurst Lane Goring On Thames Reading Berkshire RG8 9BN 01491 873588 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) evesimmons@btconnect.com Mr Charles Henry Simmons Mrs Eve Joy Simmons Ms Penny Camilla Luckett Care Home 21 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (21) of places Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 21. 30th December 2005 Date of last inspection Brief Description of the Service: Cleeve Lodge is a privately owned care home for people aged 65 and over. It is a large detached Victorian house, modernised and extended, in a quiet road in Goring. There is a lounge, dining room and conservatory on the ground floor, with bedrooms on the ground and first floors. All bedrooms are for single occupancy and five have en-suite facilities. The bedrooms without en-suite facilities are each fitted with a washbasin. The home does not provide nursing care and, when needed, district nurses from the local doctor’s surgery provide this. The current fees for this service range between £500 and £650 per week. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Cleeve Lodge was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.45 am and was in the service for 5½ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out in June 2006. A total of 16 relatives/vistitors comment cards was received and 16 residents’ comment cards. Only 2 residents were able to complete the comment cards without the help of a relative or friend. Two GPs, a consultant psychogeriatrician and 2 care managers also completed surveys about the home. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The inspector talked to the registered manager, one of the home’s proprietors, care and domestic staff, a visiting community nurse and five residents during the visit. Samples of the home’s records – residents’ care plans, medicines, information about the home (the Statement of Purpose and residents guide), staff records and maintenance – were examined. The inspector would like to thank the residents, managers and staff for their welcome and assistance during the inspection. What the service does well: There is a relaxed and friendly atmosphere in the home, and the standard of cleanliness is extremely good. This was confirmed by residents and relatives’ survey comments, such as ‘room is always beautifully clean and tidy, as are all the other facilities’; and ‘the home always smells good. Residents’ rooms and beds are always clean and clothes washed’. Professional visitors also report the good aspects of Cleeve Lodge as being ‘the physical layout of this home with high standards in terms of decoration/furniture/size of bedrooms’. Another wrote: ‘an excellent friendly home. The owner and manager are very helpful. Very homely feel. Good standard of care and my clients have been very happy there’. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some changes are needed in the homes’ contracts so that residents are given current information about the costs of their care and any additional charges that may be made together with written notice of any fee increases. The residents’ care plans should be further developed so that there is more detail about the residents’ care needs and to what extent the home has met these. Some aspects of the way the home manages residents’ medicines could be amended. The home should have a mobile hoist to help staff safely move residents in the event of an emergency such as a fall, or acute illness affecting a resident’s ability to walk or stand independently. The variety of organised activities for residents should be improved and the home should draw up and carry out an activity programme, after consulting with residents and their families about the kind of activities in the home and community that they would like. The total number of care staff who have an NVQ Level 2 in Care or its equivalent should be increased to meet the recommended total of 50 of carers with a recognised qualification. This is already being addressed by the home. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 7 Staffing numbers should be reviewed by the home to make sure that there are always enough staff available to meet residents’ care needs and taking into account the time needed for social and recreational care and training of care staff. Resident’s room doors must not be wedged or propped open because this will put residents and staff at risk should there be a fire, because open doors will not slow the spread of smoke and flames. The fire service must be consulted about suitable automatic door closers for residents who like to keep their room doors open. 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. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable: the home does not provide intensive rehabilitation care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service have sufficient information about the home in order to make a decision about whether it is likely to suit their needs. Personalised needs assessment means that prospective residents needs are identified and staff can plan for these before residents move in. Some amendments are needed to the written information and contracts for the home, to ensure they are accurate and service users are clear about the service they will receive and how much it will cost them. EVIDENCE: The inspector looked at the home’s Statement of Purpose and other written information about the home, including the contract agreements for 3 residents. The leaflet/brochure of the home is not up to date, but the proprietor intends to produce a new one if some planned alterations to the home are made in future. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 10 Laminated cards listing key information about the home, such as mealtimes and the usual domestic routine, are in residents’ rooms. The contract documents need some amendments, for example updating the regulatory authority referred to, and that the home will give written notice of any fees increase. One relative/visitor’s comment card stated that there had been a substantial rise in the fees and that the home had given an unsatisfactory explanation of this increase. The home assesses prospective residents before their admission. It has a good process, which the manager and owner continue to improve. Twelve of the 16 residents’ comment cards showed that they had received a contract, whilst 4 could not recall having one, but said that their family had a copy on their behalf. The same number of residents stated that they had enough information about the home before they were admitted, though some said they relied on information from their relatives or Social Services care manager. Where a prospective resident has a care manager the management obtains a copy of their assessment. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Written records of care should be further developed to provide staff with more detailed information about how to meet residents’ needs. EVIDENCE: The inspector examined a sample of 4 residents care records. The home has a good care planning system, using a commercially produced care record system, but day-to-day recording by staff could be improved as it was sometimes lacking in detail or scope. For example, there were gaps in the daily care entries for 2 residents: good practice for record keeping is that there should be no lines left blank between entries as this may indicate that staff are completing records some time after they were on duty, and/or could be falsified. The most recent diary entries about residents’ social/recreational care were made in September 2006: the inspector considers this may reflect a low level of activities provided in the home, and/or that staff do not consider the importance of recording this aspect of residents’ care. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 12 The written comments were bland and repetitive, such as ‘no problems. Meds given. Went to bed at [time]’ and did not reflect any positive aspects of residents’ life or that their care had met their needs. This is similar to the inspector’s findings in June 2005. Residents’ or their family’s input or agreement about the care plans was not evident in the sample seen. One person’s long-term care plan is supposed to be reviewed 6 monthly, though there was no written evidence that this had been done since December 2005. Residents spoken with during the inspection were satisfied with the medical care they receive. Eleven of the 16 resident’s survey answers showed that they ‘always’ receive the medical support they need. Others felt that they ‘usually’ found this to be the case – two had not required any medical input to date so could not comment. A visiting district nurse told the inspector that the home manager communicates well with the community nursing team so that resident’s who have need of short term care or advice from a nurse receive this promptly. Doctors’ comment cards also reflected confidence in the way in which the home communicates with them and the standard of care that residents receive. The inspector looked at the home’s medication records (MAR) and its medication storage. The home uses a high street chemist to dispense residents’ prescription medicines using a Monitored Dosage System – residents’ tablets are provided in individual blister packs for each day - for which there were all the appropriate records. However, several of the computer printed MAR sheets had handwritten additions made by staff when the doctor had instructed a change to resident’s medication. These should be signed by the GP in person or by the staff member making the entry. It is best practice to have a second member of staff to check and countersign the altered instructions to reduce the risk of mistakes being made that could result in the resident receiving the wrong medication, and the inspector recommends this is done. The doctors regularly review residents’ medicines to make sure that they are still effective for them. Medicines are securely stored in a cabinet on the ground floor. The staff have to carry racks of the medication cards around the home to give residents their tablets at various times of the day. The inspector recommends that the home considers obtaining a medicines trolley to take around the home as this would be more efficient for staff and would enable them to take other items with them, such as liquid medicines and measures, water and glasses, needed when giving residents their medicines. Residents who were asked by the inspector said that their privacy was at all times respected by staff in the home, that their private rooms were not entered without permission, and that they could receive visitors in private. The manager confirmed that residents said that residents could make and Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 13 receive telephone calls in private from a phone in the staff room, or in some residents’ own rooms, and that mail was delivered to residents unopened. The inspector noticed that bathrooms did not have ‘engaged/vacant’ indicators on the locks and recommends that privacy signs are available to use so that residents are not interrupted when bathing, using toilets or being assisted with personal care. Cleeve Lodge DS0000013073.V317957.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): 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. A limited range of activities within the home and community means that not all residents have a range of opportunities to take part in stimulating and motivating activities. Mealtimes, especially lunchtimes are an enjoyable social occasion for residents. The manager has shown a good understanding of the area of weakness and there is a good capacity for the social and recreational aspects of care to improve EVIDENCE: The inspector spoke to four residents about their experiences of life in the home. Most of the residents were in the lounge before going through to the dining room for lunch. The lounge was very tidy with one magazine that a resident asked to be passed to her. One resident asked the inspector the time and day because she ‘has no idea of the time of week’. There was no calendar and the mantel clock was not easily visible. The manager said that there is a daily paper delivered to the home for residents who do not order their individual papers and magazines, and that usually more residents would be in the Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 15 conservatory where there were magazines. The conservatory room was being used for resident’s review meetings on this occasion. The residents said they had enjoyed outside entertainers who had visited the home. They had not had a Bonfire night celebration this year. Two residents commented on the lack of a communal TV in the home. Residents said they have TVs in their own rooms ‘if they buy their own’ but its sometimes nice to watch TV together and talk about what they’ve watched. They said that a TV is brought into the lounge to watch big ‘occasion’ events. The manager explained that TV in the lounge can be a ‘conversation killer’ and intrusive, particularly for those residents who are mentally frail. However, the home does have a good stock of videos and consideration would be given to having a TV available in a communal area for those residents who want to watch. The manager said that visiting Anglican and Roman Catholic clergy supported residents’ spiritual lives. Records and residents themselves confirmed this, and also that some residents went out to church –“someone picks you up regularly if you want to go”. Some residents also go to a nearby residential home on Friday mornings, for coffee and to join in singing led by local Salvation Army members. Two visiting professionals and 2 relatives/visitors’ comment cards indicated concern about the lack of organised activities for residents for example: ‘I am disappointed there is no specific activities organiser’; ‘possibly needs more activities for people’; ‘I appreciate that most of the residents at Cleeve Lodge have some form of dementia but there is very little in the way of entertainment to stimulate them’; and, ‘my only comment is does anyone ever sit and chat to her [resident] one to one?’. Residents’ comment cards showed a mixed response to the question ‘Are there activities arranged by the home that you can take part in?’ 2 answered ‘always’, 6 ‘usually’ and 8 ‘sometimes’. Additional comments included ‘more [activities] would be good’; ‘some entertainment in the; afternoon would be a pleasure’; ‘would like someone to sit and chat occasionally’. One of the resident’s comment cards, completed with the help of their relative, wanted there to be more physical exercise - ‘I wish that s/he could be taken out on regular supervised walks – this is probably what s/he misses the most’. A Tai Chi class is advertised and takes place in the home fortnightly and residents said they enjoy this – ‘we join in whatever is put on’. Another resident spoke of her enjoyment of the garden and walking out into the park in good weather. There was some discussion about the state of the unmade road leading to the house, which is deeply potholed, and how pedestrians had to take particular care here. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 16 The manager and owner said that, despite encouragement residents often did not want to participate in organised activities. Staff members do activities, especially in the afternoons with residents, for example games, puzzles and quizzes. All respondents to the Commission’s pre-inspection survey said that they were welcomed and could see residents in private at any time. Residents confirmed that they were able to bring personal possessions and items of furniture to the home if they wished, and evidence of these was seen in residents’ bedrooms. Residents spoken with said that the meals were usually good. No one was aware of the lunchtime menu choices available that day. The residents’ comment cards showed that 6 ‘always’ like the meals; 8 ‘usually’ and 1 only ‘sometimes’. The inspector is aware that these surveys were completed some 5 months before this inspection and that changes in catering staff and menus may have affected peoples’ views over time. The inspector suggested that written menus on each dining table could be provided to remind residents of the dish of the day and the alternatives that are available. A cook is on duty each day from 9am to 2pm to prepare and serve lunch. On the day of inspection the lunch looked and smelled appetising, and the residents spoken to said they had enjoyed it very much. The cook prepared poached salmon for the first course and offered a choice of chicken to those who did not want fish, or whose food preferences were not known yet (two residents who had been recently come to live here). The day’s menu is discussed with residents mid-morning and, if a resident does not like what is planned, an alternative is arranged. Residents’ likes and dislikes are listed in the kitchen and it was evident that the cook and carers were well informed of residents’ food preferences. The cook confirmed that residents’ food preferences are discussed as part of their assessment when they come to live here, and are reviewed every month, to make sure that they continue to exercise choice about their meals. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents feel safe and listened to and staff are alert to any circumstances that could affect residents’ security and protection. EVIDENCE: Residents and relatives/visitors comment cards showed that the majority are confident about how to make a complaint if necessary, and that they feel able to discuss any day-to-day concerns with the manager or care staff. The home has an appropriate written complaints procedure. The owner said that this was sent out to every resident and their relatives and that a copy was displayed by the front door of the home. The inspector looked at the record of all complaints received and of the action taken in response. The manager said that she had not received any formal written complaints and those listed were verbal comments/concerns raised by residents and/or their representatives. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The manager had a copy of the Oxfordshire Multi-agency Codes of Practice, and she confirmed that issues relating to the protection of vulnerable adults were included in induction training and further training in safeguarding is planned for staff. Cleeve Lodge DS0000013073.V317957.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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with a safe, attractive and homely place in which to live. EVIDENCE: A programme of redecoration and refurbishment of several rooms, including 3 bathrooms and toilets, has been completed since the last inspection. The home is very clean, and decorated and furnished to a high standard. Staff said that the partner of a live-in staff member satisfactorily carries out routine maintenance as necessary. The home also employs a part time handy man/gardener. Residents and relatives/visitors were largely very complimentary about the environment of the home – ‘the home always smells good. Residents’ rooms and beds are always clean and clothes washed’; Mum’s room is always beautifully clean and tidy as are all the other facilities’. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 19 Two written comments mentioned unpleasant smells in two areas of the home, but the surveys were completed in June/July this year and these problems may have been addressed since then. The inspector did detect a smell of urine in the entrance hall on arrival and in one resident’s room (the home’s staff were aware of this and were dealing with it). The laundry room is well equipped, clean and tidy and residents’ personal clothing looked nicely laundered and ironed ready for return to their rooms. Cleeve Lodge DS0000013073.V317957.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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has plans to improve training for staff. There is a higher proportion of residents who are more dependent on staff for assistance and who would benefit from more opportunities to engage in stimulating and motivating activities; staffing levels should be reviewed and amended to take this into account. EVIDENCE: The staffing rotas and numbers of staff on duty on the day of this inspection showed that the number and skill mix of staff was a in the staffing statement agreed with the registering authority in 2001. However, the manager and owner agreed that there are now more residents who need staff assistance than formerly, and there are at least 6 residents who are mentally frail and confused. A quarter of the relatives/visitors who completed comment cards felt that there were not enough staff to meet the needs of residents. However, with one exception, written feedback was very positive about the caring and friendly nature of the staff, for example, ‘[we] have been very grateful for all the loving care our [relative] has received over the past years at Cleeve Lodge’. Of the 16 residents comment cards, 50 felt that they always receive the care and support they need and 50 that this is ‘usually’ the case. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 21 The same proportion of residents answered that staff were ‘always’ or ‘usually’ available when they needed them. One commented that ‘any delay is usually caused through shortage of staff and having to attend to personal hygiene of too many residents’. The inspector noted that several care staff work long hours and mixed day and night shifts within a week. Days off are not always planned consecutively and in some cases, staff did not appear to have any days off in a planned 2-week rota. Though staff may choose to work in this way, there is a potential for them to become overtired which may affect their work and care of residents. In view of the increased dependency of residents, and the additional need for social and recreational care of residents, and time for staff training, the inspector recommends that the proprietors and manager review the numbers of staff to make sure that there are sufficient numbers and skill mix of staff to consistently meet the residents’ needs. The inspector examined a sample of 2 staff members’ files. These were seen to be well organised and showed a systematic and thorough approach to undertaking the required checks and vetting of prospective new staff. None of the present staff has an NVQ qualification in Care, although five carers have started this training. For Standard 28 to be assessed as ‘fully met’ there must be at least 50 of carers with a minimum of Level 2 NVQ in Care. The manager is optimistic that good progress can be made with staff training now that NVQ assessor links with a local training organisation have been made. The home’s induction consists of a list of topics that are ticked off as each topic is covered. The manager said that the Skills for Council (formerly TOPSS) induction training is now in place, and staff workbooks covering the required training targets were seen by the inspector. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a programme of quality review, though the ways in which residents, staff and relatives are consulted could be further developed to involve them more in influencing how the home is run. EVIDENCE: The registered manager has worked in the home for 16 years and has gained significant management experience in this role. She has an up-to-date first aid certificate and has attended a range of training courses relevant to her work. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 23 The registered manager has completed Level 4 NVQ in Management. She does not have Level 4 NVQ in Care and this is required before Standard 31 can be assessed as ‘fully met’. The manager confirmed she has almost completed this course. Comments from visiting social and health care professionals were very positive about the management of the home: ‘an excellent friendly home – the owner and manager are very helpful’. Residents spoken with said that they do not have meetings with the manager and staff to discuss any suggestions about the way the home is run and the facilities. The manager confirmed that this is so, but said that every year at a social event, relatives are invited to set up a relatives/residents group, but to date no one has taken up this proposal. The proprietor sends out questionnaires annually to residents and relatives to obtain feedback about the home’s services. The inspector saw the most recent batch of responses that the proprietor and manager were analysing to follow up any individual issues that were raised. New residents are given an opportunity to express their opinions formally at the end of the trial period of six weeks. The inspector suggests that the proprietor and manager consider ways in which they can publish the results of resident surveys and make them available to the current residents, their representatives and other interested parties, including CSCI in order to fully meet standard 33 about quality assurance. The owner said that residents and/or their representatives were expected to manage their personal finances, and that the home did not do this on their behalf. Residents control their own money, or pass this responsibility to a representative. The staff are from a varied ethnic and cultural backgrounds, whilst the current residents are all white British. The manager and proprietor said they discuss with staff some different cultural expectations that they may encounter during their work. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Two staff spoken to confirmed that they received training in health and safety topics such as fire safety, moving and handling, and first aid during their induction and are regularly updated. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 24 The home does not have a mobile hoist. Residents are mostly physically able and can walk independently or with the aid of a walking stick or frame. However, the inspector considers that the home should have a hoist so that if a resident falls and is on the floor, or temporarily unwell and unable to walk, staff would be able to assist the resident without risk of injury to themselves or the resident. The manager said that a fire safety officer had just undertaken a fire risk assessment on the home in line with the most recent legislation. The inspector noted that two first floor residents’ room doors were propped open. Room doors should not be held open because in the event of a fire, smoke and flame spread would not be limited as intended by a closed fire resistant door. The inspector made a requirement that the home must consult with the local Fire authority about suitable fire precautions, where residents prefer to keep their doors open, or it is necessary for staff to be able to observe them as part of their care. The registered manager is the homes fire marshal and will attend update fire safety training for this role within the next 12 months. The inspector checked the fire safety logbook and found that the routine fire safety checks and staff training records were up to date. Cleeve Lodge DS0000013073.V317957.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 OP38 Regulation 23 (4) Requirement The proprietor must seek advice from the Fire Authority about approved fire safety precautions in the home. Timescale for action 28/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations Amend the statement of terms and conditions to include the way in which the service user will be notified of any fee increase, and the specific costs of any additional services to be paid for over and above those included in the fees. * Improve the detail of care plans to show the actions that need to be taken by care staff to ensure that all aspects of the health, personal and social care needs of residents are met. * Improve the written evaluation of care in the residents’ care records. 2. OP7 Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 27 3. OP9 4. OP10 5. OP12 6. 7. 8. 9. 10. OP15 OP27 OP28 OP33 OP38 * Where handwritten amendments are made to the MAR sheets, the GP should be requested to sign these as soon as possible. If care staff write in the MAR sheet, the amendment should be checked and countersigned by a second suitably trained member of care staff. * Consider using a medicines trolley to transport and administer residents’ medication. Provide privacy signs for bath/shower rooms and w.c.s to indicate when they are in use and protect resident’s privacy when undertaking or being assisted with personal care tasks. Draw up and implement a programme of activities after consultation with residents. Specific training for staff should be provided in suitable activities, especially for those residents with dementia. Provide menu sheets for residents so that they are informed about the full range of menu choices available to them Review the numbers and skill mix of staff and ensure that these consistently meet the care needs of residents. Maintain the current NVQ training programme for staff so that the home works towards achieving the recommended ratio of 50 staff with NVQ Level 2 or above. Improve consultation with residents and relatives to gain their views of the service and publish the results of resident surveys. Provide a mobile hoist for use in the event of emergency and/or short-term incapacity of residents. Cleeve Lodge DS0000013073.V317957.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Cleeve Lodge DS0000013073.V317957.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. 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