Inspection on 11/07/06 for Cumberland Care Home

This inspection was carried out on 11th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cumberland Care Home 01/04/09

Cumberland Care Home 07/05/08

Cumberland Care Home 29/05/07

Cumberland Care Home 29/11/05

Cumberland Care Home 25/03/05

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

CARE HOMES FOR OLDER PEOPLE Cumberland Care Home 67 Whitford Gardens Mitcham Surrey CR4 4AA Lead Inspector Liz O`Reilly Unannounced Inspection 11th July 2006 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 Cumberland Care Home DS0000061986.V303822.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. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberland Care Home Address 67 Whitford Gardens Mitcham Surrey CR4 4AA 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) 0208 646 1551 0208 646 5283 manager.burroughs@careuk.com Care UK Community Partnerships Limited Mr Minkailu Sama Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (48), Mental disorder, excluding learning of places disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (6) Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 28/04/2006, one named Service user (male) under the age of 65 with Dementia can be accommodated within the home. 29th November 2005 Date of last inspection Brief Description of the Service: The Cumberland Care Home is a purpose built facility situated in residential area of Mitcham. The property is detached and single storey with parking available on site. Public transport facilities are close by. The home is owned and managed by Care UK Community Partnerships Ltd, a subsidiary of Care UK plc. Care UK is a private company who own and manage a significant number of homes throughout the country. The home provides long term and respite nursing care and accommodation for up to 48 older people with dementia. Fees for this home range from £651.00 to £800.00. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two regulation inspectors. Questionnaires on the service provided were sent to a sample of staff, other professionals, residents and relatives or friends. The response from the questionnaires returned have formed part of this inspection. A fieldwork visit to the home was carried out on 11th July 2006. At the time of the fieldwork visit forty one residents were living in the home. The inspectors had the opportunity to speak with six members of staff, the home manager, six residents and three relatives. The inspectors also had the opportunity to observe interactions between residents and staff. What the service does well: What has improved since the last inspection? The environment for residents has been improved by the replacement of carpets and the redecoration of certain areas in the home. Bedside cabinets have also been replaced. Twenty staff are in the process of completing a training course on dementia care which will assist in ensuring residents are cared for by a well informed Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 6 staff group. There has also been an increase in the numbers of staff taking part in or having completed NVQ training. A number of staff have completed training on the protection of vulnerable adults. The inspectors observed an improvement in the interactions of staff with residents. Staff were observed to be engaging residents in conversation more frequently than on the last visit to the home. The home has managed the admission of a number of residents from a long stay hospital ward. Other professionals felt that the home managed this transfer very well. What they could do better: To make sure that staff are provided with full up to date information on the needs and wishes of residents a review of the way in which information is recorded needs to be carried out. A review of the care plans and assessments in place also needs to be carried out. This review needs to include checking that the cultural and religious needs of individuals are known and are being met. Where residents are prescribed medication for agitation or restlessness qualified staff should review the behaviour of individuals as part of the monthly care plan review. Communication within the home and with outside agencies could be better and the management should look into how this can be improved. All staff providing direct care need to receive regular planned one to one supervision. The training needs of all staff need to be reviewed to make sure they have up to date knowledge and skills. The keyworking system should be developed to provide more personalised care for individuals. It is recommended that more frequent staff meetings take place to assist in improving communication in the home. All staff should be informed or reminded of their individual responsibility for reporting any concerns or allegations of abuse. Care must be taken in following the recruitment procedure to ensure the safety of residents. Any gaps in the checks carried out must be attended to. Staff must be reminded to address residents by their chosen name and to offer additional drinks on a regular basis. Consideration should be given to including additional training and information on maintaining the dignity of older people with dementia and other mental health needs. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 7 A review of how residents contribute towards events in the home, obtain toiletries and are provided with funds if they run short needs to be carried out. Clear written guidance needs to be in place for this. A review of the meal times needs to take place. This review must include choices, dignity, access to menu and how cultural and religious needs are being met. One resident stated they would like to have more contact with the home manager. 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. Cumberland Care Home DS0000061986.V303822.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 Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. Residents are provided with written information on the service they can expect from the home. Staff have the necessary skills to care for the residents who are admitted. Further work needs to be done to make sure that information on the needs of each person admitted are known to staff. EVIDENCE: The statement of purpose and service user guide to the home is available in the entrance hall for visitors. Each resident is supplied with a “welcome pack” which gives information on the home and what they can expect from the service. Pre admission assessments into the needs of each individual are carried out by staff from the local authority or health authority. The home receives copies of the assessments. This ensures that staff are informed of the needs of each individual before they arrive at the home. However the inspectors found information provided in the assessments had not been used by staff in setting up the plan of care within the home. Significant information was therefore not available to the staff providing direct care to the residents. The registered Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 10 manager must ensure that all information provided is used to make sure that residents are provided with the care they require and staff have a clear understanding of the needs and wishes of each person in their care. This home does not provide intermediate care. Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. Each resident has a care plan but not all are fully completed or contain up to date accurate information. The health care needs of residents are mostly met but further work needs to be done to improve communication in the home and with outside health care professionals. The record of wound care still needs further work. Medication is well managed. Medication records are well maintained. Residents and relatives are happy with the way most staff respect their privacy and dignity. More emphasis should be placed on dignity and respect as part of the staff induction. EVIDENCE: The inspectors found care plans in place but they were not fully completed. Staff have made some progress in providing good information on the likes and dislikes of individuals. However the assessments needed to ensure the full needs of each person are met had not been completed. Assessments of needs in relation to pressure area care, nutrition, moving and handling and wound care were not in place in certain instances. In one instance no pain assessment had been carried out for a resident who was particularly unwell. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 12 At the time of the last inspection a requirement was made for care plans to be compiled in consultation with resident or their representatives. The registered manager informed inspectors that work was still going on to get relatives involved in the care planning process. Over the last eight months the home has been moving their care planning and assessment documentation onto a computerised system. The inspectors found important information provided to the home in writing had not been entered on the system. Staff therefore may not have the full information they need to meet the health and social needs of individuals. This was noted in particular with the needs and wishes of one resident, who was very unwell, regarding their religious wishes. No clear information was available on care and support to be provided at the time of death. In one instance senior staff informed the inspectors that they did not know why one resident had moved into the home. The inspectors obtained this information by reading the written information provided prior to admission. It is of concern that qualified staff have been providing care without any clear understanding of individual health care needs. The registered manager must make sure accurate and up to date information is available to all staff providing direct care. It is recommended that senior staff in the home monitor the documentation on file on a regular basis. Information must be in place on the religious and cultural needs of individuals along with how these needs will be met. Staff must take care to read the care plans for any resident they are caring for. The home has developed links with health care services. Residents have access to regular dental, chiropody and optical services. Residents are supported to attend hospital appointments. The home has links with the tissue viability nurse who will visit to provide advice. The home has good links with the local GP service. Feedback from professionals indicated that at times communication within the home has not worked properly with instructions not being passed on between staff. Communication between staff and other professionals has on occasion been less than adequate. Staff communication particularly between the qualified staff needs to be improved. Feedback from other professionals also indicated that staff have carried out good work with some very challenging residents and that standards in the home have improved over the last two to three years. The inspectors found wound care records to be inadequate. The entries in the daily record were poor. No evaluation had taken place. There were no records to indicate how the wound was to be treated. The documents did not give a clear indication as to how many stitches were in place. All qualified staff have been provided with written guidance on wound care records and it is hoped that this will improve the standard of wound care recording. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 13 Medication records are up to date and accurate. The registered manager informed the inspector that two new GPs were in the process of reviewing the medication for each resident. A significant number of residents are prescribed medication for agitation or restlessness. The daily notes do not make reference to this behaviour. In order to assist the review of medication qualified staff should review individual behavioural needs as part of the monthly review of the care plan. The manager informed the inspectors that staff are provided with clear guidance on respecting the privacy and dignity of residents at all times and that this is emphasised at the staff handover. Staff were observed to interact well with residents talking to residents on a one to one basis and offering support and advice in a discreet manner. The inspectors noted that at times certain staff addressed residents as “girl” or “boy”. Staff need to take care that they address residents the way the resident has chosen. Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. Residents have the opportunity to take part in a number of planned activities. Visitors confirmed that they felt welcome in the home. Further work should focus on how staff can support residents to exercise more control over their lives. Residents confirmed they enjoyed the meals provided. Staff need to confirm with residents and or their representatives that the cultural needs and wishes of individuals are being met. EVIDENCE: A member of staff is employed to provide activities and arrange outings for residents. Residents have the opportunity to take part in planned activities throughout the week. The activities officer was found to be enthusiastic and committed to providing individualised activities plans. Activities include arts and crafts, domestic activity, reminiscence, physical exercises, music sessions and time in the Snoezelen room. As well as group activities the activities officer also provides one to one activity or interaction. One resident stated they would like to help with the gardening and another comment suggested more classes which relatives could join. At the time of this fieldwork visit to the home one resident was celebrating their birthday with relatives and other residents involved in a tea party. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 15 Visitors confirmed they felt welcome in the home, were always offered drinks and kept informed of any changes in their relatives care. Staff were seen to assist residents to the dining room for their main meal. Residents can take their meals in their room or in the lounge area. One resident was given a “bib” by staff and told why the resident confirmed that they were happy with this. However all other residents were also provided with “bibs” with no explanation or choice given. The registered manager must ensure that appropriate options are made available for protecting clothing at meal times if needed and that staff offer clear choices to those residents who may wish to use these. The menu is on display in the dining room. However. it is in small print and difficult for residents to read. Staff should look at ways to make the menu more accessible in writing or pictorially. Staff serve the meals and residents who need support and assistance with eating were helped appropriately. Two residents said the food is “good”, one resident said the food was “ok but there was no choice”. Other comments on the meals included “they are nice” and “they are good cooks”. Feedback from questionnaires, observations and discussions with residents indicated that the majority of residents were happy with the food provided. Meal times were calm and well managed. Comments were received that indicated that the cultural needs and wishes of some of the resident group were not being catered for. The registered manager must ensure that a menu is produced with choices for those residents for who the present main menu is not appropriate. A hot drink and snack is served in the afternoon and staff were seen to help residents with eating and drinking. A jug of water and cups were available in the lounge for residents, however comments were made that cups are not always available and that the majority of residents can’t help themselves to drinks. Staff must be aware of residents needs and offer additional drinks at regular intervals. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. A clear complaints procedure is in place and on display in the home. Staff have been provided with clear guidance on reporting incidents and injuries. All staff must be provided with training on the protection of vulnerable adults. A procedure for the protection of vulnerable adults is in place. EVIDENCE: The complaints policy is displayed in the entrance home, accessible to relatives and other visitors. Discussion with residents and relatives and feedback from questionnaires indicated that people were aware of how to make a complaint should they need to. The manager reported that they have not received any complaints since the last inspection in November 2005. The CSCI are aware that an investigation into unexplained bruising had been instigated by the local authority. The registered manager informed the inspectors that an investigation had been carried out. An investigation has also taken place into an unexplained leg wound found on one resident in May of this year. Copies these reports were requested to be forwarded to the CSCI at the time of the fieldwork visit. To date these reports have not been received by CSCI. Discussions with staff indicated that they are aware of how to report any allegation or concern about abuse of residents. The manager reported that staff are provided with “in house” training on the protection of residents and Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 17 that four staff have attended the training provided by the local authority. The staff training record provided to the inspectors indicated that not all staff have taken part in training on this subject. The registered manager must review the training programme to ensure that all staff working in the home are provided with this training. All staff should be reminded of their individual responsibilities for reporting any concerns or allegations. A policy and procedure are in place for the protection of vulnerable adults and the home also has a copy of the local authority procedure. Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home is well maintained clean and tidy. The shared areas of the home provide a choice of communal space with options for meeting relatives and friends in private. Residents have a choice of assisted bathing facilities. Further work could be carried out in personalising bedrooms. EVIDENCE: The home is divided into four units with two units on each side of the building. Each two units have a dining room, two lounges, single and double bedrooms and assisted bathrooms and toilets. Progress has been made with the refurbishment and redecoration programme. The registered manager informed the inspector that a programme for the replacement of carpets had commenced and bedside cabinets had been replaced. This work needs to be continued to ensure that the décor in bedrooms and communal areas is maintained to a satisfactory standard. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 19 Certain residents have been supported to personalise their bedrooms with their own belongings, pictures and photographs. Other bedrooms are quite bare and do not reflect the residents personal interests or preferences. Consideration should be given to involving keyworkers in supporting residents to decorate their rooms with personal items. The home has a separate laundry area with appropriate equipment. The home is well lit, warm, tidy and smells fresh. Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. The home is appropriately staffed. Opportunities are available for staff to receive regular training. Care needs to be taken to make sure staff receive up to date training and refresher courses where necessary. The organisation has a clear recruitment procedure but care needs to be taken to ensure that this if followed. Consideration should be given to expanding the role of keyworkers. EVIDENCE: The staffing levels in the home are adequate to meet the needs of the residents. Qualified nurses are always available within each unit. At the time of this visit one of the two unit managers had been away from the home for some time. The lack of management in this unit may have impacted on the standard of recording and communication in this unit. The registered manager was in the process of applying for a temporary manager for the unit. The manager informed the inspectors that additional staff had been employed at night to ensure that the needs of residents are met. Comments from residents and relatives indicated good relationships between staff and residents. Comments included, “they are all lovely”, “the staff are very helpful”, “they do a wonderful job”. Feedback from one person indicated they were not happy with the staffing levels throughout the day. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 21 Other professionals commented that the home has some excellent experienced qualified mental health nurses and that all staff had carried out good work with some very challenging residents and that standards in the home have improved over the last two to three years. New staff take part in an induction programme which includes guidance on their role, orientation, health and safety and fire procedures, information about the company, the philosophy of care and residents rights. The inspectors are of the opinion that this programme should include more details on the importance of maintaining individual dignity. Twenty staff have taken part in dementia care training. This training has been provided “in house” using guidance from the Alzheimer’s Society. As noted previously all staff must be provided with training on the protection of vulnerable adults. Checks need to be made to ensure that staff receive refresher training. One member of staff took part in dementia care training five years ago. The registered manager informed the inspectors that almost sixty percent of care staff have completed NVQ level two and that senior carers will be taking part in NVQ level three training. Staff meetings are held with minutes kept. It was noted that meetings had been held in September 2005 and January 2006. It is recommended that staff meetings are held more frequently which may improve the communication within the home. The organisation has a clear recruitment procedure in place. Staff files contain a copy of the application form, confirmation that CRB check has been completed, copies of passports ,work permits where required and three files contain two written references. One staff file contained only one written reference with was from a relative of the member of staff( this issue was identified in the file of a member of staff who has worked in the home for over six years and changes in the recruitment practices have been introduced since this time). One staff file contained two references but neither were from previous employers. This was from a newly appointed member of staff. The registered manager must ensure that the recruitment procedure is followed and references include an applicants previous employer. Checks are made on the qualifications for nurses employed in the home. The home has a keyworker system however discussions with staff indicated there was no clear role for keyworkers. This system should be reviewed to ensure that keyworkers are clear about their role. Consideration should be given to developing the keyworker role. Cumberland Care Home DS0000061986.V303822.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. The manager is qualified and has the necessary experience to run the home. The home generally works in partnership with families and other professionals. Appropriate checks are carried out on the building and equipment to ensure the safety of residents, visitors and staff. Staff need to be reminded of safety issues when using equipment. Records of money held in the home for residents are well maintained. Care must be taken to make sure that residents financial contributions towards events are supported by a clear written policy. The manager is working with his line management to develop quality assurance and monitoring systems. EVIDENCE: Systems are in place to make sure that safety checks are carried out on a regular basis. Records are well maintained. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 23 Regular health and safety meetings take place which cover the smoking policy, meal breaks, maintenance, fire exits being clear, accidents, wheelchairs, reclining chairs, beds, uniforms and staff handovers, reminding staff of their responsibilities under health and safety legislation. Staff were observed to move one resident around the home in a wheelchair without the foot rests securely fixed. The foot rest was swinging away from the wheelchair as the resident was moved along the corridor and into the dining room. Staff must be reminded of the importance of using equipment correctly. A record of accidents and or incidents is maintained in the home. Incidents have occurred following which these records have not been completed. The inspectors are aware that all staff have now been provided with written instructions on the reporting of accidents. The registered manager must monitor the recording systems to ensure that records are maintained and if required outside agencies including the CSCI are notified in good time. Facilities are available for residents to deposit small amounts of cash in the home for safekeeping. Records of money held for each individual are well maintained, up to date and accurate. Examination of these financial records indicated that residents contributed different amounts for special events in the home. The registered manager must ensure that there is a clear policy on residents contributions. The records also indicated that the bulk buying of toiletries has been taking place. Consideration should be given to keyworkers arranging individual toiletries for residents which would support a more person centred approach. Feedback from professionals indicated that at times communication within the home has not worked properly with instructions not being passed on between staff. Communication between staff and other professionals has on occasion been less than adequate. The registered manager should look at improving the communication systems within the home and with outside agencies. Individual staff supervision is not taking place on a regular basis. It is important that all staff receive regular, planned one to one supervision. This will allow staff the opportunity to discuss individual training needs and any concerns they may have. Supervision will also provide the management opportunities to check that all staff are working towards the stated aims of the home, are performing to their full potential and will improve communication within the staff group. Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 24 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 2 x 2 Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) Requirement The Registered Persons must ensure that care plans and assessments are completed, are up to date and accurate. The Registered Persons must ensure that care plans are compiled in consultation with residents and if appropriate their representatives. (timescale of 01/04/06 not met) The Registered Persons must ensure that details of how the cultural and or religious needs of individual residents will be met. (timescale of 20/02/06 not met) 4. OP8 17(1)(a) Sch 3(k) The Registered Persons must ensure that a clear record of wound care is maintained. (timescale of 20/01/06 not met) 5. OP15 16(2)(i) 12(4) The Registered Persons must carry out a review of meal times to include promoting choice in the food provided, access to the DS0000061986.V303822.R01.S.doc Timescale for action 20/11/06 2. OP7 15(1)(2) 20/11/06 3. OP7 12(4) 15(1)(2) 20/11/06 20/11/06 20/11/06 Cumberland Care Home Version 5.2 Page 26 menu, addressing the cultural needs and wishes of individuals and protective clothing. Additional drinks must be offered on a regular basis. 6. OP18 13(6) The Registered Persons must ensure that all staff working in the home are provided with training on the protection of vulnerable adults. All staff must be reminded of their individual responsibilities for reporting any concerns or allegations. 7. OP30 18(1)(c) The Registered Persons must ensure that the training on dementia care is provided to all staff, to a level appropriate to their position in the home. Regular updates must be provided for staff who have received this training in the past. The Registered Persons must ensure that all staff are provided with training on the improtance of maintaining privacy and dignity at all times. 8. OP29 19 The Registered Persons must ensure that the recruitment procedure is followed at all times. The Registered Persons must provide to the CSCI information on how quality monitoring and quality assurance will be carried out in the home. The Registered Persons must ensure that clear written guidance is available on individual finance. A copy of this DS0000061986.V303822.R01.S.doc 05/01/07 05/01/07 20/11/06 9. OP33 24 05/01/07 10. OP35 17 (2) Schedule 4 20/11/06 Cumberland Care Home Version 5.2 Page 27 document must be supplied to the CSCI. 11. OP36 18(2) The Registered Persons must ensure that all staff providing direct care are provided with regular one to one supervision from a more senior member of staff. The Registered Persons must ensure that all accidents and incidents are recorded and reported appropriately. The Registered Persons must ensure that staff use wheelchairs and any other equipment in a safe manner. 20/11/06 12. OP38 17(1)(a) Sch 3 (j) 20/11/06 13. OP38 13(4) 20/11/06 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. 4 Refer to Standard OP9 Good Practice Recommendations The Registered Persons should ensure that qualified staff review individual behavioural needs as part of the monthly review of care. The Registered Persons should consider involving keyworkers in supporting residents to personalise their bedrooms. The Registered Persons should review the role of the keyworker in the home to ensure that staff have a clear understanding of their role. The Registered Persons should investigate ways in which communication within the home and with outside agencies can be improved. OP19 OP27 OP36 Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Cumberland Care Home DS0000061986.V303822.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!