Inspection on 17/06/08 for Cumberland House

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Good service.

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 House 14/08/07

Cumberland House 30/04/06

Cumberland House 06/12/05

Cumberland House 21/08/05

Cumberland House 11/02/05

Cumberland House 01/09/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Cumberland House 21 Laton Road Hastings East Sussex TN34 2ES Lead Inspector June Davies Unannounced Inspection 17th June 2008 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 House DS0000021084.V366447.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 House DS0000021084.V366447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberland House Address 21 Laton Road Hastings East Sussex TN34 2ES 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 422458 Linda@chouse21.fsnet.co.uk Mrs Linda Gratton Mrs Linda Gratton Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eighteen (18) Service users must be older people aged sixty five (65) years or over on admission Service users with mental health needs, excluding dementia, only to be accommodated To allow one specific resident who is under 65 years of age to be accommodated 14th August 2007 Date of last inspection Brief Description of the Service: Cumberland House is registered to provide accommodation for up to 18 older people suffering from a mental health issues and admits people with low to medium dependency needs. The home currently has an exception statement in place, which allows for one resident to be placed under the age of 65 years of age. The premise is a large detached property situated in Hastings. It has mainly single rooms (three doubles) situated on the first and second floors (most of which are en suite, all have a wash hand basin). Residents have the use of a lounge, conservatory (smoking area), dining room and kitchenette on the ground floor. There is no lift and the home is not suited to those with mobility problems. The home has a large well-maintained rear garden with seating and lawn area for residents to enjoy and the front garden also has seating for residents. Ample car parking is available within the street outside and the home’s driveway. The building is located a 15 minute walk from the town centre, is close to a bus stop and a shorter walk to the nearest shops. The home currently has 13 residents. The service’s range of fees are from £336.74 to £383.37 per week. The lower rate is based on what East Sussex pays. The higher rate is based on what London boroughs pay. Those who are self funding [private] pay he same as what the lowest rate is and receive the same facilities as those funded by Social Services. The latest Inspection report is sent out to any enquirer who expresses an interest in the home. A copy of the report is obtainable via the manager. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was carried out on Tuesday 17th June 2008 over a period of seven hours. During this inspection the inspector carried out a tour of the home, spoke with 12 residents, carried out an audit of medication, observed staff working with the residents, spoke to two members of staff, and looked at all documentation relevant to the key standards inspected. This was also compared with the Annual Quality Assurance Assessment (AQAA) submitted to The Commission for Social Care Inspection by the registered manager/provider. Three requirements and two recommendations were made at this key inspection. What the service does well: Cumberland House provides a warm, comfortable home for the residents to live in. Residents are able to maintain choice over their lives and many independently access the local community on a daily basis. The home provides a variety of activities that residents can choose to be involved in. The food provided in the home is of good quality. All residents spoken to said that they enjoyed the food in the home, and said that they were able to make choices in what food they would like to eat. The home has good working relationships with external health care practitioners, and there was good evidence that when necessary residents have good access to all external health care practitionerds. The receipt, administration, storage and return of unused medication is well managed. From observation during this key inspection staff have good working relationships with the residents in the home. Staff respect the privacy and dignity of the residents. All the residents spoken to said that the staff treated them with kindness and respect. The registered provider/manager and deputy manager have worked hard to meet the requirements made at the last key inspection. There was evidence that the managers have good working relationships with the residents. Residents spoke highly of both the manager and her deputy, saying that Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 6 nothing was too much trouble for them, and they were all very happy in the home. What has improved since the last inspection? What they could do better: There was a requirement made at the previous key inspection that staff levels must be revised to ensure that staff are employed in sufficient numbers, this requirement has been partially met, in that the registered provider/manager has employed sufficient cook hours to ensure that there is a cook on duty seven days per week. Generally staffing hours are good, due to the manager and her deputy working in the home with care staff when staff sickness or holiday, leaves the rota short. But it was noted by the inspector that on some occasion’s only one member of staff is on duty, and a requirement has been Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 7 made that care staff hours must be revised to ensure that the needs and safety of the residents are met. Generally staff recruitment procedures are good, but from viewing staff files the inspector noted that one recent member of staff was employed with only one reference and a requirement has been made that two written references must be obtained prior to a new member of staff being employed by the home. The registered provider/manager has produced a good quality assurance system for the home, but has not put this into practice. A requirement has been made to ensure that this quality assurance system is implemented, and an annual report is produced on the findings of this quality assurance check is produced. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cumberland House DS0000021084.V366447.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 House DS0000021084.V366447.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6 People using this service experience Good quality outcomes in this area. Each new resident will move into the home knowing they have a contract of residence. New residents will have a pre-admission assessment to ensure that the home is able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the present time there are thirteen residents at Cumberland House, one of these residents is presently in hospital. There have been no new residents in the home since the last key inspection. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 10 A new contract (statement of terms and conditions) has been developed, this will require the new resident’s signature or the signature of the relative/representative, it will also state the room that they will occupy together with the weekly fee charged and whom will be responsible for payment of this fee. The deputy manager was able to show the inspector that a new pre-admission form has been devised; this will be completed for all new residents in the future. The form requires an in depth assessment of the prospective residents needs and this together with assessments carried out by external authorities, will give sufficient information on which to base a decision as to whether the home can meet the needs of the resident. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using this service experience Good outcomes in this area. The care plan system is consistent and adequately provides staff with the information they need to satisfactorily meet the residents’ needs. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. Personal care is offered in a way to protect the residents’ privacy and dignity and promote independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans have been redesigned to ensure that all the health, physical, mental and social care needs of each resident is identified. The inspector viewed three Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 12 care plans and each contained details of daily care needs, medical history, psychiatric history, medication, personal care needs, social interests and preferences, likes and dislikes, inventory, daily reports, and risk assessments. Some of the risk assessments were generic and other were relevant to a particular resident. The daily care needs chart on each individual car plan tells staff what daily care needs are for each resident, and how they can assist the resident with meeting these needs. The care plan also has information regarding strengths, weaknesses and goals for each resident. The inspector evidenced that these care plans had been reviewed each month and that the resident had been involved in this review. With exception of one resident most of the residents in the home are selfcaring, but need prompts from staff in relation to their personal hygiene needs. Bath charts also showed that staff record any concerns they may have in regard to tissue viability, staff record when a resident has a shave, and ensure that hair care is recorded. One resident in the home at the present time is frail and unable to get out of bed; a specialised air mattress has been obtained to ensure that pressure areas remain intact. Any concerns that staff may have are reported directly to the general practitioner. One resident requires continence aids and these have been obtained on their behalf. Any concerns regarding psychological health are referred directly to the Community Mental Health Team, who then gives the home assistance in overcoming these concerns. With the exception of one resident all other residents in the home are able to exercise themselves on a daily basis, by going out of the home for a walk, or walking around the home and the garden of the home. Staff ensure that residents are weighed on a regular basis and any concerns are reported directly to the residents general practitioner. There was good evidence on each care plan to show that residents have access as and when required to external health care professionals, as well as opticians, chiropodists and dentists. The inspector carried out an audit of medication and found that Monthly Administration Records (MAR) are appropriately signed off after the administration of the medication prescribed. However it was noted that dividers are not used between each resident’s MAR sheet(s). The inspector did observe that liquid medication is not dated on the day of opening. The home has up to date Policies and Procedures (reviewed in February 2008) relating to the administration of medication, use of and recording of controlled Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 13 drugs and the use of homely medications. All staff administering medication have received medication training. The home does not have a stock of medication, and at the present time does not have any residents who require Controlled Drugs. From observation during a tour of the building the inspector noted that staff respect the privacy and dignity of the residents. Staff talk to the resident in a kindly and understanding way. Twelve residents were spoken to during this inspection all praised the staff and are happy with the care they receive. Residents said that in general they would visit the general practitioners surgery, but three residents said that a general practitioner has been to see them in the home and they were able to see their general practitioner in the privacy of their own bedroom. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use this service experience Good quality outcomes in this area. There are a variety of activities on offer within the home, and residents have good daily contact with the community. Visitors are welcome in the home at any time. Residents are able to maintain control over the lives unless they choose not to. The meals in this home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have a variety of activities on offer to them within the home; such a board games, playing cards, reading newspapers/books, listening to their favourite music, aromatherapy, reflexology and watching their favourite Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 15 television programmes. They are able to choose when they wish to go to bed and get up in the morning. Many of the residents go out of the home on a daily basis to the local shops or into Hastings town centre. The inspector witnessed one of the residents telling the manager that he was going to catch a bus into Hastings. Another resident attends a church in St Leonard’s on Sea every Sunday for the morning service. A staff member, to ensure residents are safe, escorts some of the residents on trips out. On the first Sunday in every month a inter denominational church visits the home to give a church service, and on every Thursday afternoon a lay preacher visits the home to talk to residents and play music on the electronic organ. Residents care plans have a sheet which states who they wish to or do not wish to have visits from. Visitors are welcome in the home at any time. With the exception of one resident all other residents in the home have a nominated power of attorney that manages their finances for them. There is information within the home in regard to advocacy services. All residents may have access to their care plan at any time. The inspector observed a lunchtime meal and noted how the residents use these occasions to socialise with other residents. The menus are produced on a four weekly basis, and show that residents are offered a nutritious, varied and healthy diet. While menus do not show choices, residents themselves were able to confirm that if they did not like the main menu of the day, they were offered a choice of other meals. All twelve residents spoken to said that the food in the home was very good, and they always enjoyed their food. One resident said, ‘The food in this home is excellent, it is the best food I have ever had.’ Another resident said, ‘I always enjoy the food it is well cooked and I have the right amount for me.’ The home is able to cater for specialised diets but at the present time only needs to cater for diabetic diets. One resident from time to time prefers to have his food liquidised, and this is done with each item being liquidised separately so that it is presented to the resident in an attractive and appetising manner. Cumberland House DS0000021084.V366447.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using this service experience Good quality outcomes in this area. Residents know that their complaints will be listened to and acted on. Staff have a good knowledge and understanding of Adult Protection issues, which protects the residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure has been updated in January 2008. This now gives comprehensive details of the complaints process. The deputy manager has devised new complaints and suggestions forms. The complaints policy and procedure is clearly displayed in the home. There is a complaints file and this contains details of the investigation of the complaint and reply made to the complainant. Since the last key inspection residents in the home have made two complaints and these have been dealt with appropriately. Three residents said that they would know how to make a complaint and know whom they would make the complaint to. The protection for vulnerable adults policy and procedure has been updated and is specific as to the forms of abuse that can occur. The home has a Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 17 whistle blowing policy and procedure that clearly outlines what staff should do if they suspect that abuse has occurred. There have been two adult protection issues since the last key inspection, both of these have been investigated and are now closed. All staff working in the home have received Protection of Vulnerable Adults training, and abuse is discussed in one to one supervisions. New staff recruited to work in the home complete a ‘Skills for Care’ induction and this also includes safeguarding vulnerable adults training. The deputy manager was able to show the inspector that they have a copy of the Sussex Multi-disciplinary procedures for Safeguarding Vulnerable Adults. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 People using this service experience Good quality outcomes in this area. There has been no change in the décor of the home in the last 12 months although this does not pose a risk to the residents, the manager is aware that the home needs some attention. Infection control procedures are in place to protect the residents living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector carried out a tour of the premises this included all communal areas, residents bedrooms, the kitchen, the laundry and the back garden. The Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 19 home was found to be clean, warm, spacious and provides comfortable and homely accommodation for the residents who live in it. The back garden is safe and secure and provides a pleasant place for the residents to sit in the fresh air. The shared bedroom had a screen to provide privacy. All bedrooms were clean, well decorated and furnished. The registered provider/manager said that she is aware that some parts of the home look tired and need redecorating, and that when bedrooms become vacant these are then redecorated. One communal bathroom on the top floor needs some attention to the sealant around the bath. The kitchen was clean and well ordered, and evidence was seen that temperature checks for the fridge and freezer are carried out daily; a record is kept of all food eaten by the residents. The laundry is situated in the basement of the home, and has an industrial washing machine and industrial tumble drier. The laundry room floor is impermeable to water. It was noted that a toilet provided close to the laundry room was being used for storage, and should be available to staff so they may wash their hands prior to carrying out further tasks. At the present time the home has no clinical waste. Disposable gloves and plastic aprons are provided for care staff. There were no offensive odours in the home. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People using this service experience Adequate quality outcomes in this area. Staffing levels have been improved upon for ancillary staff, but further improvement needs to be made for care staffing hours to ensure that the assessed needs of the residents are met and that residents are safe at all times. The home is working hard to ensure that sufficient staff are employed on each shift who are qualified and have received and updated their mandatory training. Recruitment practices have improved since the last inspection but further work needs to be done to ensure that staff are appropriately vetted and residents are not at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector viewed the staff rota and observed the number of staff on duty. The rota shows that there are two carers on duty on the 8.00 am to 2.00 pm shift and 2.00 pm to 8.00 pm shift and one member of waking night staff 8.00 Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 21 pm to 8.00 am with the registered provider/manager or deputy manager on call. Where there is a shortage of staff through sickness or annual leave either the registered provider/manager or deputy work hands on with the other carer. However it was noted that there have been instances where just the registered provider/manager have been carrying out care duties. A requirement was made at the previous inspection that staffing hours should be reviewed this requirement has been partially met in that the registered provider/manager has ensured that sufficient cooks hours are provided to cover cooking at the weekend. Care staff hours must be improved upon as leaving one member of staff on duty from time to time does not ensure that the needs or safety of the residents are being met. A requirement was made at the last key inspection regarding staff levels and this has been partially met a further requirement is being made to ensure that care staff are employed in sufficient numbers to enable two care staff to be on duty during the day time shifts and this includes weekends. Failure to implement this requirement will result in enforcement action being taken. From conversation with residents in the home residents told the inspector that there was always a staff member there when required. At the present time 37 of care staff have gained their NVQ qualification, with one member of staff working towards their NVQ and another member of care staff having just enrolled on the NVQ course. When these members of staff have qualified this will bring staff with NVQ qualifications to 62 . The inspector viewed two staff personnel files and found that while all new staff complete an application form, there was not a full employment history and a written record for gaps in employment. Both staff have a Criminal Records Bureau check and have been checked against the Protection of Vulnerable Adults register. It was noted however that while one file had three written references the other file only had one written reference. The registered provider/manager and deputy explained that while the member of staff had given the names and addresses for two references to be applied for, one was an old employer and no-body working in this service could remember this member of staff being employed by them. References should be followed up prior to a member of staff being employed, and a requirement is being made that in future two references are received prior to the registered provider/manager deploying this person to work in the home. All files had at least two forms of identification and a recent photograph. The inspector looked at the training matrix and found that the following percentages of staff had completed their mandatory training – Moving and Handling 0 ; Fire Safety 87 ; First Aid 75 ; Food Hygiene 64 ; Protection of vulnerable adults 100 ; Medication 100 although some staff need to do refresher training for this; Infection Control 64 . There was also evidence that staff had undertaken work related training. All new staff in the home receive and introductory induction and go Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 22 on to complete a ‘Skills for Care’ related induction within the first six weeks of their employment Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 People using this service experience Good quality outcomes in this area. The manager is supported well by her deputy manager, and the manager has a good understanding of what needs to improve in the home. Systems are in place for the monitoring of quality assurance in the home but need to be implemented to ensure that residents receive the best quality of care. Residents’ personal allowances are well managed by the home, and residents know that their own personal monies are safe and secure. Staff receive regular formal supervision to ensure they have the skills and knowledge to meet the residents needs. The registered manager/provider ensure that health and safety issues are well managed to ensure the residents and staff live and work in a safe environment. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 24 This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the registered provider/manager and deputy manager have NVQ level four and Registered Managers awards as well as other qualifications. There is evidence that both update their knowledge and skills by attending other training courses. The management ethos in the home is open and management are available to both residents and staff. The registered provider/manager and deputy work cover shifts and work with care staff out in the home. Residents when in conversation with the inspector spoke highly of the provider/manager and her deputy, saying they were very kind. Comments from three residents were, ‘Nothing is too much trouble for them.’ ‘They make you feel they really care about you.’ ‘I went into hospital and when I came out the manager had done this room for me, look how nice it is, look at the curtains, everything is very nice.’ The registered provider/manager has developed a quality assurance system for the home but has not put this into use. The inspector was shown evidence that questionnaires for residents, relatives and professional visitors are in place, as well as Health and Safety and Fire Risk Assessment, and forms for monitoring systems used in the home. This system must be used and a requirement made at a previous inspection while being partially met is requiring that the quality assurance system is now used to ensure that the home is offering all residents a high quality standard of care. These questionnaires and monitoring of systems should be used in a quality assurance report developed at the end of the year and made available to the residents and a copy sent to The Commission for Social Care Inspection. A requirement has been made that the registered provider/manager implements this system. Five residents have chosen to have their personal allowances looked after by the home, each has a personal account sheet, when ever they need money they request this, outgoing are recorded onto their personal account sheet. Where expenditures are made on behalf of the residents, receipts are kept. Each resident has their own envelope with where personal allowances are kept. The home only keeps a small amount of money for each of these Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 25 residents, and if this starts to build up, the money is paid into a residents building society account. All monies and account sheets are kept separately and securely in the home. From viewing staff personnel files, there was evidence that staff receive formal supervision at least six times per year. All the equipment used in the home have current maintenance certificates. During a tour of the premises the inspector noted that domestic staff keep the cleaning materials cupboard locked. All windows are fitted with window opening restrictors. Hot water is supplied from an independent boiler and does not deliver water over 43ºC. The home has up to date health and safety policies and procedures. Any identified risks have a risk assessment attached. All accidents are recorded in a Health and Safety Executive accident book, from viewing these accident forms the inspector noted that only two falls have occurred this year. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 26 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 27 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 OP27 Regulation 18 (1)(a) Requirement Timescale for action 18/08/08 2. OP29 19(4)(C) Schedule 2 (5) 24 (1)(a) (b)(2)(3) 3. OP33 The registered person must ensure that care staff are employed in sufficient numbers, to ensure that there are always two care staff on each daytime shift. Staffing hours must be kept under constant review to ensure that all the assessed needs of the residents are met. The registered person must 18/08/08 ensure that two written references are obtained prior to deploying a member of staff to work in the home. The registered person must 01/09/08 ensure that she implements the quality assurance system she has in place to ensure that residents, visitors and professional stakeholders views are sought, that systems used in the home are monitored on a regular basis and that full health, safety and fire risk assessment are in place for each room in the building and the external area of the home. Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations The MAR sheet folder should have dividers between the MAR sheets for each resident, these dividers should have a photograph of the resident, to clearly identify them. Liquid medicines should be dated on the bottle on the day of opening. All staff must receive mandatory training within the first six months of their employment, and this should be updated as required. Due to the age of the residents in the home all staff should receive ‘Moving and Handling’ training. 2. OP30 Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cumberland House DS0000021084.V366447.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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