Inspection on 29/10/07 for Cleeve Lodge

This inspection was carried out on 29th October 2007.

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

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

Other inspections for this house

Cleeve Lodge 24/11/06

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 Jill Chapman Unannounced Inspection 29th October 2007 10:20 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.V349583.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.V349583.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.V349583.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. 24th November 2006 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 weekly fees range from £525 to £675. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.20am and was in the service for seven 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. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector toured the building and spoke with residents individually and in a group at lunchtime. Records relating to care, staffing and health and safety were sampled. the inspector had discussions with the Proprietor, Manager and two staff on duty. Some of the daily routine and a lunchtime meal was seen. What the service does well: Residents receive up to date information about the home to help them decide whether it is suitable for their needs. The home does not admit residents unless they can meet their needs. Prior to agreeing an admission the home would assess whether it could meet any specific religious or cultural or dietary needs. Up to date care plans help staff meet residents’ needs. Residents and relatives say that care needs are well met. Residents are supported to access health care and to take their medication. Residents know that their privacy and dignity is upheld. Residents benefit from in house activities and community contact and these are being further developed. Residents are supported to exercise personal autonomy and choice. They benefit from a healthy and appetising diet and their likes and dislikes are taken into account. Residents and relatives know that their concerns will be properly dealt with. Staff are trained to know how to protect residents from potential abuse. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 6 There are sufficient trained staff to meet the residents current care needs. A robust recruitment policy is in place to make sure that staff are suitable to work with vulnerable residents. Residents and others know that the home is well managed by a qualified and supportive manager. The proprietor and manager are accessible to residents and others. The home seeks the views of others to develop the service. Health and safety systems are kept up to date. Relatives surveyed said: ‘My relative is always clean, clothes are well laundered and they look well fed’, ‘No complaints at all about Cleeve Lodge’, ‘the home looks after them in a nice friendly way’ ‘Personal care is good. Always tidy and well-groomed, clothes beautifully kept and well ironed.’ ‘Residents are well fed, when ill they are given a special diet and weighed regularly.’ ‘Home kept spotlessly clean and well cared for, room spotless and bedding changed frequently.’ ‘The staff are very caring and maintain high standards in the cleanliness of residents rooms, laundry, personal hygiene, medical attention and meals. There is a very happy atmosphere and every effort is made to help the relatives feel at home and cared for.’ A staff surveyed said, ‘I think the service we provide is very good all round.’ A GP surveyed said, ‘If able, always brought to surgery with a member of staff who knows the resident well’ ‘Sees residents as individuals and arrange appropriate care with GP or Nurses”. A District Nurse surveyed said, ‘the care home generally feels like a happy and caring home where residents can live a happy caring life…’ Health professionals surveyed said ‘Due to the owner and managers hard work and dedication Cleeve Lodge is a great example of how a care home should be’ ‘The care at Cleeve Lodge is excellent. The staff are invariably considerate, helpful and caring and help us to help them. Staff are polite, not condescending, helpful and professional. They deal with challenging behaviour with great care and skill.’ A Social Worker said the home does well in coping with residents with challenging behaviour and dementia. What has improved since the last inspection? Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 7 Since the last inspection the bathrooms and toilets have been refurbished and the garden made secure. Replacement equipment includes a new cooker, washing machine with sluice facility, tumble drier and carpet cleaner. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cleeve Lodge DS0000013073.V349583.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.V349583.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, 2, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive up to date information about the home to help them decide whether it is suitable for their needs. The home does not admit residents unless they can meet their needs EVIDENCE: There is a Statement of Purpose and Service Users Guide in place and both documents have been reviewed since the last inspection. Surveys confirmed that residents and relatives received enough information about the home to help them decide whether it met their needs. The manager confirmed that these documents can be made available in large print or other formats and this needs to be made clear so they can be requested if needed. A recommendation to amend the Statement of Terms and Conditions to include costs that are not included in the fees has been carried out. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 10 Written information submitted by the home prior to inspection shows that prospective residents are fully assessed prior to admission, to make sure the home can met their needs. The files of two new residents were seen and these assessments show that all areas of need are covered. The pre admission assessment includes looking at whether there are any specific cultural, religious or dietary needs. The home has reviewed and updated its admission form since the last inspection. The home does not offer an intermediate care service and so Standard 6 does not apply. Cleeve Lodge DS0000013073.V349583.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 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Up to date care plans help staff meet residents’ needs. Service users and relatives say that care needs are well met. Some relatives would benefit from more information about toileting programmes. Residents are supported to access health care and to take their medication. Residents know that their privacy and dignity is upheld. EVIDENCE: A recommendation to further improve care plans has been met. A new care plan format is in place that contains the information required. Records of daily care have improved although the manager still needs to monitor some entries that say ‘no problems’. Up to date photos of the individual residents have been added to the care plans. Care plans are reviewed monthly with residents and relatives. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 12 There was good feedback from surveys about personal care needs being met. ‘My relative is always clean, clothes well laundered and looks well fed.’ ‘Since being in the home, my relative looks well and healthy and a health problem has cleared up with the care received.’ There are toileting programmes in place for some residents but evidence from surveys show that these could be clarified for some relatives. A health professional surveyed said that staff deal with challenging behaviour with great care and skill. A Social Worker surveyed said the home does well in coping with residents with challenging behaviour and dementia. As part of the care planning process individual risks to residents are identified and documented. Some risk areas need further development, for example bathing and risks associated with Dementia. Bathing risk assessments should cover the risks of falling, drowning and scalding. There is good evidence that residents’ health care needs are met. A local NHS dentist has been found and residents confirmed that staff take them to the surgery see the GP when needed. A GP surveyed said ‘If able (residents) are always brought to surgery with a member of staff who knows the resident well’ ‘ (the home) sees residents as individuals and arrange appropriate care with GP or Nurses. A District Nurse surveyed said ‘Good communication, very caring, attentive to individuals needs and very supportive of District Nursing team’ ‘good communication re individuals care needs, for example end of life care for residents with complex health care needs’ The manager and proprietor said that they have good working relationships with a variety of health professionals. They said that the Community Psychiatric Nurse and Psychiatrist have been supportive with any mental health issues. The home has an appropriate system in place for the storage and administration of residents’ medication. A recommendation to make sure that the GP or a senior member of staff countersigns any amendments made to the medication records has been carried out. The manager and proprietor are still assessing whether the use of a medication trolley to transport the medication files to give residents their medication would reduce health and safety risks to staff. Staff confirmed that they are given induction training on the homes medication procedure and further training in their Common Induction training and from the Pharmacist. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 13 Up to date photographs have been added to residents’ medication files to ensure that the right medication is given to the right person. Medication is kept securely stored and records are kept of returned medication. There is a system for the storage, administration and recording of any Controlled Drugs. It was seen that staff treat residents with respect and protect their privacy. Health professionals see them in private. Privacy notices have been put in place for bathrooms and toilets as recommended at the last inspection. The proprietor said she is looking for replacement door locks with a type that is easier for elderly resident to use. Cleeve Lodge DS0000013073.V349583.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 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from in house activities and community contact and these are being further developed. Residents are supported to exercise personal autonomy and choice. They benefit from a healthy and appetising diet and their likes and dislikes are taken into account. EVIDENCE: Residents confirmed that there is flexibility in the homes routines. Some like to go to bed early and others like to stay and socialise in the lounge. At lunchtimes most like to come and eat in the dining room but some prefer to eat in private in their bedroom. A recommendation to implement a programme of activities in consultation with residents is under way. The manager said that the home is continuing to develop activities available to residents and thought is being given to meeting the differing needs of the resident group. All care staff have received Dementia training to help them understand the need of these residents. A volunteer comes to the home twice a week to help engage residents in activities and some residents go out to a local lunch club once a week. Residents said they Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 15 particularly liked the Tai Chi activity held every fortnight. The proprietor said there are a number of social events planned for the Christmas period, visits by the local Brownies for Christmas Carols and tea, a visiting cabaret act, relatives drinks and supper party and two church services. Some residents spoken with and relatives surveyed felt that day-to-day activities could be further improved. ‘Provide more stimulation, find time to chat to the residents and employ someone to look after the social side of the home.’ ‘Needs to be more stimulation, more activities in afternoon and more time for staff to chat to residents.’ A staff surveyed thought that taking residents out would provide more stimulation but acknowledged that this would be difficult to resource. The manager and proprietor are planning to see if there are additional community resources available. Currently, when they have time, care staff engage in spontaneous activities with residents, armchair exercises or walks in the garden and this could be recorded to better evidence this. Relatives and residents confirmed that visitors are made welcome in the home. However some relatives commented that certain staff lack small talk and can appear unfriendly and do not volunteer how their relative has been. In discussion with the manager and proprietor it was felt that a recent management emphasis on confidentiality might have influenced how comfortable some staff feel in greeting relatives. They agreed to help staff strike the right balance. The home does not look after any residents’ monies or financial affairs, relatives or solicitors look these after. Individual and Lockable units for residents bedrooms are available for those who request these and this should be made clear in the Service Users Guide. There was good feedback from residents and their relatives about the quality and quantity of food available. Menus are varied and reflect the type of meals popular with an elderly resident group. As recommended from the last inspection, menus are now made available to residents to let them see what choices are available. There is a list of individual likes and dislikes kept in the kitchen and residents confirmed that choices are available. Meals are home cooked by staff and fresh ingredients are used. A relative surveyed said, ‘Dietary likes and dislikes catered for.’ Sometimes menus include the choice of individual residents favourite ‘treat’ meals, for example jellied eels or a weekend ‘fry up’. Staff are aware that familiar food can trigger happy memories from past years. There are no specific religious or cultural dietary needs at present and the manager said that they would look at these needs in the admission assessment to see if they could be properly met. Residents weight is checked monthly to monitor any weight or health related dietary needs. Staff are trained in food hygiene and food and fridge/freezer checks are carried out daily to make sure Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 16 food is correctly cooked and stored. The inspector joined residents for a lunchtime meal. It was appetising and hot, with an accompanying choice of salad items served at table by staff. Staff assisted residents who needed help in a friendly and dignified way. A relative surveyed said that, ‘Residents are well fed, when ill they are given a special diet and weighed regularly.’ Cleeve Lodge DS0000013073.V349583.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives know that their concerns will be properly dealt with. Staff are trained to know how to protect residents from potential abuse. EVIDENCE: The Commission has not received any information from residents or others about any complaints about the home. The home has an appropriate complaints procedure, which has been reviewed and updated recently. Copies of the updated procedure have been sent to residents and relatives. Residents and their relatives confirmed that they know who to talk to if they have a concern. The complaints record shows that complaints are dealt with and outcomes are recorded. A relative survey said, ‘ When my relative has a concern, I go directly to the owner of the care home, who deals with the problem immediately, face to face. The owner has a sympathetic attitude and is very approachable.’ Another relative surveyed said ‘No complaints at all about Cleeve Lodge’ Staff spoken to knew what to do if a resident has a concern and they are told about the complaints procedure in induction training. The manager keeps any letters of thanks and compliments from relatives or professionals and shares these with the staff. The inspector saw a letter that was recently received from a solicitor praising the care of a resident he had visited in the home. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 18 The Commission has not received any information about any safeguarding adult referrals relating to the home. Staff receive training in how to protect residents from potential abuse and this is regularly updated. There is a copy of the up to date local Safeguarding Adults Policy in the home and the manager and proprietor know what to do if there is a concern about a vulnerable adult. A Community Psychiatric Nurse surveyed said that the home dealt well with a difficult situation between vulnerable residents. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 19 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, 21, 24 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from well-maintained and comfortable accommodation. Home is kept clean and hygienic. Residents laundry is well cared for. EVIDENCE: The inspector toured the building and found that the home is well maintained, nicely decorated and furnished. Feedback from relatives and residents is that the communal areas and residents’ bedrooms are always kept very clean. Communal rooms are bright and airy and give a good feeling of space. Some residents said they particularly like the conservatory and sit together with their friends to socialise. It is clear that there is a rolling programme of redecoration, replacement and refurbishment. Since the last inspection the bathrooms and toilets have been refurbished and the garden made secure. Replacement equipment includes a Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 20 new cooker, washing machine with sluice facility, tumble drier and carpet cleaner. There are plans to refurbish the kitchen. Residents bedrooms seen were well cared for and homely, upstairs rooms have good views of the local countryside. There are attractive gardens with a large accessible patio. The home is kept clean and hygienic; all care staff share the domestic tasks. All staff have been trained in Infection Control. There is a good size laundry with appropriate equipment. There was good feedback from relatives about how well laundered resident clothing is and how nicely they are dressed. A relative surveyed said, the home is kept spotlessly clean and well cared for, the bedroom is spotless and bedding changed frequently.’ Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 21 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 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient trained staff to meet the residents current care needs. A robust recruitment policy is in place to make sure staff are suitable to work with vulnerable residents. EVIDENCE: A previous recommendation, to review the numbers and skill mix of staff has been carried out. An extra morning care staff had been deployed at the time of the last inspection, to meet the needs of the more mentally frail residents. Out of five staff surveys returned four said there were usually enough staff to meet residents needs and one said always enough staff. Out of six residents surveys returned three said they usually and three said they always received the care they need. Three said staff are always available and three said they are usually available when you need them. Out of seven relative surveys received, two said that the home usually meets the residents care needs and five said that the home always meets the care needs. One staff surveyed said they need more carers when people are off. This overall feedback represents a positive improvement from the last inspection and it is clear that the manager and proprietor are continuing to monitor any increases in residents needs. Since the last inspection all care staff have received training on Dementia and Palliative care to meet the individual needs of some residents. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 22 As highlighted in the last inspection report, rotas sampled show that some staff still work long shifts and some work additional shifts when they are available. In discussion it was clear that the manager and proprietor monitor this situation to make sure it is safe for residents and staff. Health and Social care professionals were complimentary about the way that staff care for residents and their knowledge of their needs. A health professional surveyed said, ‘Staff are polite, not condescending, helpful and professional.’ It was observed that staff treat residents with courtesy and respect. There is a stable staff team and staff morale is good. A staff surveyed said, ‘I enjoy where I work as the staff are committed to the residents needs and we all work as a team.’ Staff communication is good; there are regular handovers and staff meetings and a message book to pass on information to the manager and proprietor. A previous recommendation to maintain the current NVQ training programme so that the home works towards achieving the recommended ratio of 50 staff with NVQ 2 or above, has been carried out. The home has a programme of National Vocational Qualification training in place and is aiming to reach 50 of staff qualified, however one staff has recently left who was NVQ trained. The files of two new staff sampled showed that the home carries out a robust recruitment procedure. This includes Criminal Records Bureau and Protection of Vulnerable Adults list checks, two references and a full work history. Records show that where there is doubt about a reference, an extra referee is sought. Staff spoken to confirmed that their recruitment was properly carried out. All new staff have Common Induction Training and a workbook is completed. The manager monitors that mandatory staff training is kept up to date. Staff spoken to confirmed the training courses that they had undertaken and copies of certificates are held on file. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents and others know that the home is well managed by a qualified and supportive manager. The proprietor and manager are accessible to residents and others. The home seeks the views of others to develop the service. Health and safety systems are kept up to date but some improvements are needed. EVIDENCE: The home is managed by an experienced manager who has NVQ 4 in Management and has just completed her NVQ level 4 in Care. The manager regularly updates her practice and has recently taken Palliative Care and an advanced Dementia training course. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 24 The manager and the proprietor, who also works in the home, have clear and complimentary roles and work well together. Previous requirements and recommendations are fully carried out There is good evidence that there is consistent and accessible management. A staff surveyed said, ‘both the manager and owner are very approachable and helpful; with suggestions for improvement. They give me enough support and I feel I can always talk to the manager or owner if I have any problems.’ A health professional surveyed said ‘Due to the owner and managers hard work and dedication Cleeve Lodge is a great example of how a care home should be.’ The proprietor sends out annual questionnaires to residents and relatives to obtain feedback about the home. These are analysed and used to improve the service. A recommendation to make the results of these available has been carried out. The owner and manager said that the outcomes would be fed back to relatives and residents, possibly via the Christmas newsletter. There is s formal supervision system in place and staff spoken to confirm that they have planned and documented meetings with the manager, approximately six weekly. It was seen from health and safety records sampled and pre inspection information provided that equipment is regularly serviced and health and safety checks are carried out. A previous requirement relating to two residents doors being wedged opened has been carried out. These doors are no longer wedged open and have been adjusted to make opening them easier. Some health and safety systems need further development. Cleaning products are currently kept in a two cupboards in the laundry but should have locks to keep them secure and prevent accidents. Recorded checks to hot water outlets should be carried out more frequently; it is recommended that these be carried out weekly. Bathing risk assessments need to be developed to show that the risks of falling, scalding and drowning have been assessed. Health and safety checks of the building and equipment should be formalised by carrying out monthly-recorded audits, showing any faults and action taken. Although there are manual handling and individual risk assessments in place, the manager should seek advice from the environmental health officer and develop environmental health and safety risk assessments. Cleeve Lodge DS0000013073.V349583.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 X 2 Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13.4c Requirement Cleaning products are currently kept in two cupboards in the laundry but should have locks to keep them secure and prevent accidents. The manager should seek advice from the environmental health officer and develop environmental health and safety risk assessments. Timescale for action 29/11/07 2 OP38 13.4c 29/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP38 OP38 Good Practice Recommendations Recorded checks to hot water outlets should be carried out more frequently, it is recommended that these are carried out weekly Bathing risk assessments need to be developed to show that the risks of falling, scalding and drowning have been assessed. Risk assessments to identify risks associated with Dementia should be developed. DS0000013073.V349583.R01.S.doc Version 5.2 Page 27 Cleeve Lodge 3 OP38 Health and safety checks of the building and equipment should be formalised by carrying out monthly-recorded audits, showing any faults and action taken. Cleeve Lodge DS0000013073.V349583.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 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.V349583.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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