Inspection on 15/08/06 for Cumberland Court

This inspection was carried out on 15th August 2006.

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

Cumberland Court 18/01/06

Cumberland Court 24/05/05

Cumberland Court 19/10/04

Cumberland Court 20/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cumberland Court 6 Cumberland Gardens St Leonards On Sea East Sussex TN38 0QL Lead Inspector Jason Denny Key Unannounced Inspection 15th August 2006 08:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cumberland Court DS0000042898.V301808.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 Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberland Court Address 6 Cumberland Gardens St Leonards On Sea East Sussex TN38 0QL 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) 01424 432949 PJP Care Ltd Mrs Julie Piercy (ENID) Elizabeth Crotty Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20) Service users must be older people aged sixty-five (65) years or over on admission 18th January 2006 Date of last inspection Brief Description of the Service: Cumberland Court is situated in a residential area of St Leonards-on-Sea in East Sussex. The premises which are of the Victorian era are situated a short walk from a pleasant park, local shops, a mainline railway station and approximately 1km from the promenade and beach of St Leonards and the English Channel. The home is situated on a quiet road. Cumberland Court benefits from a homely feel throughout and is well decorated. The home benefits from a long, well maintained, and decorative rear garden. This garden is generally inaccessible to Residents with mobility needs. The home is exploring several plans, the most recent being the construction of a level path around the side of the home linking the front entrance and back garden. The home is registered to provide services for up to 20 persons. The home has 16 single and 2 double rooms [for married couples]. A number of bedrooms [7], along with communal space, are below the National Minimum Standard. The home is except from these standards due to being a pre-existing home before their implementation in April 2002. The owners of Cumberland Court, PJP Care Ltd also own a care home in Eastbourne with an experienced Manager who conducts monthly inspections of Cumberland court. The home benefits from an established and settled staff team who have worked in the home for a number of years. Information on the range of fees charged is within the homes current statement of purpose/service user guide and ranges from £348 to £390 per week. The higher rate of fee is based on room size and facilities. Charges for extras include personal items beyond the basic toiletries and activities provided by the home. Such items include newspapers, perfumes, chiropody, and hairdressing. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 8.45am and 2.30pm on August 15,2006.This inspection focused on the key major areas such as how needs are being met. Areas inspected included Activities, lifestyles, environment, staffing of the home, how the home is managed, and how concerns are dealt with. During this inspection process, which covers the period since the last inspection January 18, 2006 and the week of the home visit, a number of questionnaires [8] were received from relatives, and 8 from Residents with comments mainly positive, especially about the care, manager, and the staff. Some visitors and 8 residents were spoken with, along with others observed during the inspection, which also included discussion with some staff and observation of care-practices. The focus of the inspection was looking at the three newest Residents who have moved in over the last year. Some diversity and equality areas were explored in relation to lifestyles. Care records for three [3] Residents along with health and medication needs were looked at. Discussions with management looked at progress since the last inspection. The inspector toured all communal areas of the home along with some bedrooms. Meal arrangements were examined. A record of complaints was inspected. Staffing was looked at in detail along with the homes management, including measures to ensure quality for Residents and promotion of choice. Six [5] areas are Good, and one [1] area is Adequate [ok] and in need of minor improvement. What the service does well: The home particularly benefits from a stable staff team many of whom have worked in the home for a number of years. Dedicated and skilled staff provide excellent care to residents. Comments from visitors to the home continue to be highly positive. All residents spoken with described the service as good and attentive with special praise for the staff and management. Comments included “ cannot hope for a better place”, “very nice and attentive staff who teat us well”, “good food, enjoy activities”, “always something going on “, “staff do anything for you”, “staff respond very quickly at night when you pull the cord”. The atmosphere of the home was found to be friendly and unhurried with all residents receiving prompt and patient attention. Health needs continue to be promptly met with good information in care-plans including detailed written and regular reviews. There are regular daily activities in place, which are popular with residents. The home continues to be clean and homely. Visitors, residents, and staff stated that the management of the home was open and helpful with care being good. The home regularly Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 6 uses a range of measures to improve quality and support Residents to make suggestions including detailed monthly inspections by the organisation. What has improved since the last inspection? 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. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 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 Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 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): 1, 2, 3, & 4.. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing Residents, with a good level of information. Moreover, the way in which the home assesses prospective or existing residents ensures, that it currently meets needs. Contractual terms and conditions are fair, transparent and agreed and signed by residents and their representatives at the point of entry into the home, with only some minor additional information needed. EVIDENCE: A copy of the home’s service user [Residents] guide including a complaints procedure is on display in the reception area along with the most recent Inspection report. The guide was found to have been updated in July 2006 and also contains a survey of resident’s views following completed questionnaires received in November 2005. This positive report also included quotes from residents. The Organisation’s senior manager also records resident’s views during his monthly inspection visits, with reports sent to the Commission. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 9 The 3 Residents files looked at showed that the home now writes to prospective new residents to confirm that they could meet assessed needs prior to admittance. Pre-assessments carried out by the manager were found to be thorough with additional information from social services also obtained by the home either prior to or on admittance. These assessments accurately described the needs of the residents concerned who the inspector met with. The manager is now aware of indicating in the assessment information why the Individual is being accommodated in the home to assist staff when the reason is less obvious. Since the last inspection the owner of the home has made copies of Residents contracts available to the manager who stores them on file. Each room has its own individual fee depending on size and facilities such as en-suite. It was positively noted that of the contract looked at for the newest Resident and who is self funded pays less [£330] then some of those who are social services fully funded. This contract was also found to have been signed on admittance and included the fee to be charged and the room number. It was also evident that variations in fees are also due to social services sometimes negotiating a lesser payment than the usual advertised charge for each room. Some minor improvements were recommended, that the contract terms and conditions shows that is responsible for paying the fee as this information had to be sought elsewhere. Secondly, that the contract also shows the intended fee to be charged alongside what is actually charged in case any Resident decided to challenge it, That the contract shows whether the fee would be different if the person was self-funding and that any charges for extras are shown on the same document. The home was made aware of amendment to Care Homes Regulations effective from September 2006 in relation to contracts. Residents spoken with confirmed that they had opportunities to have trial visits before moving in although in the main they relied on their relatives to make a decision. The most recent admission was found to have visited several days before moving in, for lunch and a tour of the home. The Manager has introduced a form for recording when trial visits are offered and declined. A completed [inquiry] sheet was seen which is completed prior to a visit. Evidence was also seen of the home sending out its guide to prospective new Residents all of whom confirmed that they had opportunity to read the information before moving in. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 10 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 Good. This judgement has been made using available evidence including a visit to this service. The manager and staff are very aware of Residents needs and respond quickly to any changes. Care-plans are much improved, show Resident involvement, and contain good detailed and regular reviews. Medication arrangements have further improved with the home just needing to record the rationale for each individual’s medication in order to monitor effectiveness. Residents are treated with dignity and respect with their wishes sought and respected. EVIDENCE: Three [3] Individual plans of care were inspected relating to the newest residents and were found to be sufficiently detailed, up to date, and contained clear information to support staff to meet the needs of residents. The plans were found to be user-friendly and covered the full range of health needs, which the inspector observed during the inspection. The plans also showed in Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 11 detail how changing health needs such as stomach related issues are responded too. The quality of the reviews has improved along with their regularity, with a focus on the strengths of the individual had how to maintain their interests and independence. One particular plan showed in detail someone’s recovery after a broken joint. Bathing guidelines are detailed and show what the resident can do for himself or herself. The only section of the care-plans where detail was lacking was in relation to recording the effects of medications so staff are aware and can monitor for side effects. The manager indicated one case where a service user had moved in on aspirin, and then complained of stomach pain the home liaised with the person’s GP, [although the previous GPs notes had not been yet been transferred] to review medication with the situation eventually addressed by the relative who informed the home that aspirin had been incorrectly prescribed as the person had a previous stomach problem which this drug would irritate. In light of this the manager agreed to ensure that as far as possible such medication information is sought on admittance during the assessment process. The home was found to be mindful of how to prevent the risk of falls with some focus on ensuring the right footwear. Missing person profiles had been filled in with photographs especially for those who go out independently. Care-plans, observations, and discussions with Residents and staff showed how Resident’s personal care needs are sensitively met with full regard given to their rights, dignity, and respect. Comment cards filled in by relatives all indicated satisfaction with the care being provided to residents. Particular mention was made of how well the home supports those who become ill. The inspector looked at medication stocks, record keeping, training records and observed trained staff dispensing medication all of which was found to be in order. The Manager discussed the range of checks carried out in relation to medication arrangements. Medication is stored in a dedicated medication cabinet along with some filing cabinets, which are locked. A previous concern related to the medication cabinet visible from the homes Main reception hallway area due to this office area being open plan. The home has sought advice from the relevant medication custody guidelines and liaised with the supplying pharmacy about the best way to improve security this has resulted in a new system of key security where the keys are signed for and are kept by one designated person no service users were found to be receiving controlled drugs with the medication cabinet having double security for such items. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 12 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 Good. This judgement has been made using available evidence including a visit to this service. The home provides a good range of activities based on resident preferences and which are advertised and regularly reviewed with residents Routines are flexible for Residents who are treated as individuals and regularly consulted about their choices. Food is under constant review and is good, tasty, varied, and healthy, in good portions and is popular with Residents who have a range of choice. EVIDENCE: The Manager and staff stated that they have a flexible approach to care with Residents treated as individuals. This was confirmed by discussions with visitors, residents, and looking at records. The Inspector observed how Residents are given the support they require in such a way as to ensure their comfort and independence. Residents have previously mentioned how the home’s owners regularly support those interested, to go on a variety of outings especially in the Summer and other seasonal events such as the Pantomime season. During the morning of the inspection a number of residents received chiropody care and during the afternoon all residents had the opportunity for a Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 13 manicure as observed. Residents informed the Inspector that they recently enjoyed a trip to Bexhill and more recently a garden party which most attended. Some enjoy visits from the Methodist church and the Salvation Army on a monthly basis. A music entertainer visits fortnightly an activity attended by most residents. One resident informed the Inspector that she particularly enjoyed the bingo and baizes, which occurs once a week. The inspector saw an activity board which is on display in the lounge and which is regularly updated which also includes an Art Club and animal handling [cuddle bunnies] Movement and motivation twice a month, along with sherry mornings Residents were observed to exercise a number of freedoms such as the right to go out for a walk independently subject to an agreed risk assessment. Those who do not attend many of the activities confirmed to the inspector that they are always offered the opportunity and are kept up to date. Visitors to the home continue to confirm the flexibility afforded to them in relation to their visits. A number positively completed comment cards and met with the Inspector at the last Inspection. Residents confirmed satisfaction with these arrangements. The home was found to have a written visitors policy, which has recently been updated. The manager has over the last year introduced Residents meetings with these generally occurring quarterly the last one being in July 2006 with the manager due to present to the owner of the owner some Residents suggestions about meals. Decisions such as the choice of a bedroom key are carefully recorded in careplans along with activities and dietary preferences. A meal was sampled at the last inspection and was found to be tasty, well cooked, and healthy. Menus contain two clear choices along with individualised diets for some residents based on their choices and needs. All residents spoken with along with comment cards [with one exception] given to the Inspector indicated a good level of satisfaction with the meals provided by the home. Breakfast routines were looked at and showed in discussions with residents and the manager that breakfast times are flexible with such meals served to residents in their rooms between 6.45 and 7.45am. Residents are taken a cup of tea between 6 and 6.30am. One relative’s comment card was concerned that breakfast was actually being served to everyone around 6-6.30am with the manager explaining that this is possibly being confused with when a cup of tea is taken to residents. The inspector also saw from the kitchen/s menu board the range of different breakfasts served. All residents spoken with indicated satisfaction with breakfast times and indicated they had the choice. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 14 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 Good. This judgement has been made using available evidence including a visit to this service. The home operates in an open manner and has not had a formal complaint about the care of Residents for several years and since the new owners took over. The home maintains a clear record of complaints made and advertises a clear procedure which Residents and visitors are aware of. Staff continue to demonstrate a sound understanding on how to prevent and report abuse in accordance with the homes updated policy. EVIDENCE: The home has a comprehensive complaint policy. This procedure and forms are in the reception area to the home. There was no record of any complaint made to the home since 170404, which was fully dealt with by the previous owners and is recorded in the complaints book. Since the last inspection there have been no concerns or complaints expressed to the home or to the Commission. It is evident that the manager’s and staff’s promotion of an open culture has encouraged residents to feel confident about raising any issues or views which are regularly sought through meetings and monthly section 26 inspection visits by the senior manger. All staff cover the homes policy on adult protection and prevention of abuse during their induction. Evidence was seen of video training followed by marked Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 15 exams for the staff team as a whole. Staff who spoke with the inspector demonstrated a full understanding of all the issues involved, including whistle blowing and who to report concerns too with awareness of where the policy was kept in the home along with the contact phone numbers. The homes policy in that area was updated in January 2006 with all staff signing the updated policy, which includes the relevant contact numbers. This policy is based around the local social services guidelines. The manager has identified a formal training course in adult protection in January 2007 followed by a train a trainer course in February 2007 with the plan to cascade further training to staff within the next 6 months. The manager has also covered adult protection / abuse issues within the foundational degree she started last year All Residents spoken too confirmed the sensitive care they receive and were knowledgeable about whom to report concerns too. Staff was observed by the inspector to operate in an appropriately caring and patient manner. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 16 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 Adequate. This judgement has been made using available evidence including a visit to this service. The home was found to be clean, warm, and homely. The home is well-maintained including bedrooms and will more fully meet needs when communal areas such as the Garden are fully accessible. Communal space and some bedrooms are below the size indicated in the national minimum standard although this is not affecting outcomes EVIDENCE: A tour of all communal areas took place along with some bedrooms [where residents were spoken with] and bathrooms where all areas were found to be clean and met residents needs. One resident confirmed that she is on a waiting list for a larger room although she had declined one on a higher floor. The manager confirmed that she is now in a position to organise this as a vacancy has arisen. The location of the home is suitable for its stated purpose. The premises were found to be well maintained, comfortable and in general met Resident’s individual and collective needs. The home was found to be Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 17 bright and free from hazards. Some carpets have been replaced since the last inspection which one resident spoken with is particularly pleased with, as it has improved his bedroom. The large garden at the rear of the house does not have disabled access. The Garden is good to view and well maintained but because of a steep drop from the house level the main garden is inaccessible to all but the very agile. Access to the outside patio area, which borders the garden, is through the kitchen or via the front of the house, both routes are unsafe for anyone with mobility needs. Some comment cards completed by Residents and relatives indicated that they find accessing the garden through the kitchen “less than ideal”. A few of the residents confirmed that they do use the garden in the Summer with staff indicating that this amounts to 2-3 residents. Some recently attended a garden party. The current owner has over recent inspections discussed a future plan to extend the street level patio with an area of decking to be reached via patio doors from the dining room. During this inspection the manager indicated a new plan suggested by a relative that of erecting a path from the front door around the side of the house is being considered and is indicated on the home’s current maintenance and meal plan April 2006-March 2007 for discussions and quotations. The management of the home are mindful of open plan layout of the office along the Main throughway of the ground floor, as this makes the maintenance of confidentiality more challenging. The home was found to be clean along with bathrooms having paper towel drying facilities. The home also employs a cleaner who works most days in addition to care staff. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 18 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 Good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of experienced staff on duty who are well supervised and who continue to benefit from increased training. Tight recruitment procedures are followed for the employment of care staff to protect the interests of Residents. All Residents and visitors praised the quality of the staff. EVIDENCE: Staffing levels included 2 per day shift plus the hands on manager and 2 additional staff, cleaner and cook, for the 14 residents on the day of the inspection[ 2 recent deaths and one Resident in hospital]. An additional person now works a 4-8 pm shift to ensure that there are at least 2 staff on the care-side when the evening supper is being prepared and when the kitchen is being cleaned. Staff described this improvement as extremely useful. The home has 1 waking night person and uses an additional sleep-in when required. The manager indicated that this additional person was used recently when overall care needs were higher No current residents were found through discussion, observation, or care-plans, to need more than 1 person day or night to assist them. The rota/roster shows the capacity and role that each person works in the home. All Residents spoken with indicated that there was enough staff to promptly meet their needs. Two relatives indicated in comment Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 19 cards that they felt that just I night staff person was not enough. No evidence was found to show that this was affecting outcomes for Residents. A newer staff person confirmed at the last inspection how helpful she found the home’s in- house induction, which includes 2 weeks of shadowing senior staff. Written records showed how the in-house induction had been carried out with the deputy manager. A newer staff person who works both care and as a cook indicated how she had competed the national approved induction and the National Vocational Qualification level 2. Records looked at showed staff receiving regular written supervision. Records and the manager indicated that at least half the care staff [50 ] has now achieved at least National Vocational Qualification level 2. Since the last Inspection staff have done refresher food hygiene workbook training with the cook booked on a formal course, along with medication training. Most care staff have done first aid or refresher training since the last inspection with the manager working towards all night staff having this qualification as they usually work on their own. All staff have recently done Moving and handling practical training with a suitably qualified instructor. Two staff is working through their National Vocational Qualification level 2 and the basic TOPPS induction. Further training planned over the next year includes care-planning, infection control, tissue viability, and falls management Three examples of employment records relating to newer staff were inspected and showed that all necessary checks had been carried out prior to those people starting work in the home such as two written references being received, POVA checks carried out, and full Police CRB checks applied for. Staffing files were found to better organised since the last inspection with records destroyed of those who have ceased to work in the home for several years. No evidence of checks was found on a part time maintenance worker who worked in the home once a week since the last inspection and has recently left. The manager indicated that the owner of the home would have decided on what checks were carried out with such records possibly held at the organisation’s other home he worked in. The manager was made aware that any worker in the home needs to have full background checks carried out and so it is useful to have copies in any home the person works in. This was not found to be affecting outcomes and the person no longer works for the organisation and was never alone with any Residents at any time. The manager confirmed the all-necessary checks would take place for the prospective new maintenance person. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 20 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 Good. This judgement has been made using available evidence including a visit to this service. The management of the home is good. An exceptional range of Quality assurance measures are regularly carried out based on Residents views Record keeping such as service user finances and health and safety is good. The safety needs of Residents are well supported by the home. EVIDENCE: The new manager has managed the home since June 2005 and was successfully registered in February 2006, She has previous relevant experience in a deputy manager role. Comments from Residents, staff, and relatives indicated that the manager continues to be helpful, motivated and competent. The manager has made improvements to the homes administration. The Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 21 manager was found to still be studying for the relevant management qualification National Vocational Qualification level 4 in management and care along with the Register Managers Award. Delays have occurred on this course due to the training provider with the manager now hopeful of completing the course over the next year. An experienced manager now visits the home and carries out detailed unannounced monthly inspections of the home with full reports sent to the Commission which identify areas for improvement and gives the manager key support. These reports are detailed and include interviews with staff and Residents which genrate action plans to make further improvements. Residents views were surveyed in November 2005 with a full report published in the homes guide [see standard 1]. This review shows excellent satisfaction ratings by those residents taking part. The homes policies and procedures file was examined which showed that they had all been updated since the last inspection with staff encouraged to read and sign to show understanding. The management of resident’s monies was found to be sound in relation to the sample inspected at the last Inspection which showed an accurate running total and itemised records of expenditure, complemented with receipts. A number of residents manage their own finances with some preferring the home to maintain safe storage, which only the management have access too. Staff supervision records showed that all staff are now being regularly supervised. Staff spoken with confirmed how helpful this formalised system is, with it occurring at least every two months. Staff confirmed that they are provided with a copy of their written supervision. Health and Safety training for staff has further improved with the exception of fire training. The manager has identified that staff have not received practical training from a suitably qualified person and agreed with the inspector that it will be useful for staff to be trained on how to use the fire fighting equipment and on occasions have unannounced fire drills. An announced fire drill took place during the inspection as planned by the manager who was observed discussing the fire policy with all staff present. The home maintains a list of all Residents and their own individual needs in the event of a fire. The manager was advised to complete a written evaluation after each fire drill to keep records up to date. All necessary equipment as indicated in homes pre-inspection questionnaire completed by the manager was described as being within it servicing schedule. A recent Environment health officer inspection 150306 made some recommendations in relation to the kitchen, with the home now planning to shortly replace the existing kitchen in March 2007. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 22 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 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 2 X 4 X 3 3 X 2 Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 23 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 23[4][d] Requirement That the Registered person must ensure that Staff receive suitable fire prevention training in the form of practical training by a suitably qualified person in the use of Fire fighting equipment. [That the Registered Person confirms to the Commission by the date shown that this training has taken place.] Timescale for action 15/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations That the Statement of Terms and Conditions [Contract] shows who is responsible for paying the fee. That the usual room fee is shown alongside the actual fee charged/negotiated. That the contract shows whether the fee would be different if the person was self-funding. That any charges for extras are shown on the same document. [Amendment to regulation 5 effective from September 1, 2006] That the effects of medication and the reason for them DS0000042898.V301808.R01.S.doc Version 5.2 Page 24 2 OP9 Cumberland Court 3 4. 5 OP19 OP31 OP38 being given to individuals is recorded [In the Care –plan]. That full consultation takes place with stakeholders during the pre-assessment process. That the Garden is made accessible to Residents with the provision of disabled access. That the Manager completes the necessary qualification [National Vocational Qualification 4 in Care and Management/RMA] as soon as is practically possible That a written evaluation is carried out after each fire drill. That some fire drills are unannounced. Cumberland Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Court DS0000042898.V301808.R01.S.doc Version 5.2 Page 26 - 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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