Inspection on 30/12/05 for Cleeve Lodge

This inspection was carried out on 30th December 2005.

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 24/11/06

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 Annette Miller Unannounced Inspection 30th December 2005 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 Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 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.V275820.R01.S.doc Version 5.1 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) 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.V275820.R01.S.doc Version 5.1 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. 17th June 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. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 12 midday to 4.30pm. During this time a tour of the building took place and documents were inspected. The inspector spoke to a group of residents in the lounge about their care, as well as speaking to a carer about staff training. Ms Penny Luckett (Registered Manager) was in the home throughout the inspection. In order to gain an overview of the standards inspected during 2005/6, the previous inspection report should also be read. What the service does well: What has improved since the last inspection? What they could do better: Radiators are not fitted with covers and this potentially places residents at risk of sustaining burns from hot surfaces. This situation must be risk assessed and regularly reviewed, ensuring that action to reduce risk is taken as needed. The washing machines do not have a sluice cycle and this results in carers sluicing foul linen by hand, which potentially increases the risk of cross infection. Advice from the Environmental Health Department must be sought to ensure the home’s laundry procedures are safe. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 6 Temperature control valves have been fitted to baths and wash basins used by residents, but the effectiveness of these valves is not regularly checked to ensure hot water is kept in the region of 43ºC. Checks should be started. 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. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards was assessed on this occasion. EVIDENCE: Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards was assessed on this occasion. EVIDENCE: Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meals in this home are good, offering both choice and variety, as well as catering for special dietary needs. EVIDENCE: There is a separate dining room leading off the main lounge, with a conservatory beyond. The décor and furnishings are particularly good in these communal rooms, providing residents with an attractive and homely place to live. 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 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. All staff involved in preparing and serving food attend basic food hygiene training, including regular updates, and training certificates were seen as evidence of this. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff have a good knowledge and understanding of adult protection issues which protects residents from abuse. EVIDENCE: 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. The owner, manager and seven carers attended adult protection training on 21st November 2005. A carer said she had found the training very useful, as it made her more aware of the different types of possible abuse. Training on data protection is planned. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The standard of cleanliness within this home is good, providing a pleasant environment in which to live. However, the procedure for washing foul laundry is not adequate and potentially increases the risk of cross-infection. EVIDENCE: Cleanliness was extremely good and the home smelled fresh throughout. The home’s laundry facilities increase the risk of cross-infection because the two washing machines provided are domestic machines that do not have a sluice cycle. The manager explained that foul linen was sluiced at a laundry sink by staff before putting it in a washing machine. Foul linen should be placed in an appropriate bag that dissolves during the wash cycle. Foul linen should be washed at a minimum temperature of 65ºC for not less than ten minutes in order to thoroughly clean linen and control risk of infection. The manager was unable to confirm that the washing machines reached this temperature. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 13 Hand washing facilities are provided with liquid soap, but not paper hand towels. Instead, cloth towels are supplied but these can harbour bacteria and should not be used as they increase the risk of cross-infection. A cloth towel was seen at the sink in the kitchen servery. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 The home’s induction training gives new workers some knowledge of practices and procedures, but does not cover all the training targets required. Therefore, there is no assurance that induction training is adequate. EVIDENCE: None of the present staff has an NVQ qualification in Care, although two carers have started this training and two are planning to start. 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. New workers are not initially counted in staffing numbers and ‘shadow’ an experienced member of staff until they are assessed as being competent to provide care by a senior member of staff. The home’s induction consists of a list of topics that are ticked off as each topic is covered. The manager explained that the Skills for Council (formerly TOPSS) induction training is planned and that workbooks covering the required training targets have been ordered. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The manager provides clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Improvements in some areas of health and safety are needed to ensure residents’ safety. EVIDENCE: The registered manager has worked in the home for several 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. 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 had started this training. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 16 The proprietor sends out questionnaires annually to residents and relatives to obtain feedback about the home’s services. The last questionnaires were sent in December 2005 and five had been returned at the time of inspection, all with good comments. New residents are given an opportunity to express their opinions formally at the end of the trial period of six weeks. Residents control their own money, or pass this responsibility to a representative. The owner does not permit staff to take on this responsibility. The home’s radiators are not fitted with covers and, therefore, there is a potential risk of residents sustaining burns from hot radiator surfaces. All residents should be risk assessed to establish whether or not they are at risk of touching or falling against radiators, and a record of the outcome kept. Action to reduce risk must be taken as needed. The manager confirmed that temperature control valves are fitted to baths and sinks used by residents. Regular checks are needed on the effectiveness of these valves to ensure that hot water is kept at a temperature of approximately 43ºC. During the past year this check had only been carried out once. Handling and moving training was last arranged in October 2003. An update is overdue and the manager confirmed this would be arranged as soon as possible. All staff have attended fire training in the past 12-months. Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 17 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 Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Cleeve Lodge DS0000013073.V275820.R01.S.doc Version 5.1 Page 19 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 OP26 Regulation 13(3) Requirement The proprietor must seek advice from the Environmental Health Department to establish correct procedures for washing foul laundry, and inform CSCI of the outcome. Every resident must be assessed regarding risk of sustaining burns from uncovered radiators, and the outcome recorded. Action to reduce risk must be taken as needed. Timescale for action 28/02/06 2 OP38 13(4) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP26 OP38 OP38 Good Practice Recommendations Hand washing facilities for staff should include paper towels. Radiators should be fitted with covers. Carry out regular checks on the effectiveness of temperature control valves fitted to baths and basins used by residents, and record the outcome of such checks. DS0000013073.V275820.R01.S.doc Version 5.1 Page 20 Cleeve Lodge Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 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.V275820.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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