Inspection on 10/02/06 for Cumberland Lodge

This inspection was carried out on 10th February 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cumberland Lodge 17/07/07

Cumberland Lodge 06/12/06

Cumberland Lodge 17/10/05

Cumberland Lodge 03/03/05

Cumberland Lodge 28/09/04

Cumberland Lodge 04/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Cumberland Lodge 22 Cumberland Avenue Southend On Sea Essex SS2 4LF Lead Inspector Valerie Buckle Unannounced Inspection 10 -13 February 2006 11:00 th th Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 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 Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cumberland Lodge Address 22 Cumberland Avenue Southend On Sea Essex SS2 4LF 01702 602361 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr David Houghton Mrs Judith Anne Hatley Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One resident over the age of 65 Personal care to be provided to 12 service users with a Mental Disorder, excluding Learning Disability or Dementia (MD). 17th October 2005 Date of last inspection Brief Description of the Service: Cumberland Lodge provides 24 hour residential care for up to twelve people with mental health issues. The home is situated within a residential area close to Southend Town Centre, with Westcliff and Leigh on Sea a short distance away. There are good bus and train links to the area. The home currently has ten single and one shared bedroom, which are located on the ground and first floor, as well as a detached annexe to the rear of the property. The home has a large well maintained garden to the rear of the property and sufficient off street parking facilities. Residents within the home access the local community independently or with staff support. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours and involved three separate visits to the home. Not all the standards were inspected at this inspection, a sample of policies, procedures, records and practises were inspected, a tour of the premises took place. The registered manager and a support worker assisted in the process of the inspection, time hours spent talking to residents about their lives at the home. Four of the six requirements from the last inspection had been met the two good practice recommendations were being carried out. One new requirement was identified at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Some improvements are required in relation to the security of the building, a system must be put in place, which involves that all staff regularly checks all entrance doors are closed and locked. Regulation 26 visits to the home must take place each month by the registered provider and a report should be written and forwarded to the Commission. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 6 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 Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 New residents have the information they need to make a choice about living at the home. Residents are assessed prior to admission to the home and have the opportunity to visit the home on a trail bases. All residents are provided with a Statement of Terms and Conditions and have a contract with the home. EVIDENCE: No new resident have been admitted to the home since the last inspection. Documentation of the most recent resident admitted which was August 2004 was seen to contain a care programme approached which incorporate preassessment and included relevant information to support the homes assessment from professionals involved in his care. Evidence was seen to indicate that the resident had visited the home prior to admission. Statements of Terms and conditions of the home and individual contracts of the residents were to be signed and dated included in individual residents files. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9, 10 The care planning systems written the home reflect individual residents needs and have clear detailed instructions on how care is to be provided by support staff. Individual residents are empowered and supported by staff to make daily discussions about their lives and to be involved in the running of the home. EVIDENCE: Four care plans seen identified the support needs of the residents and were supported by risk assessments. Daily care notes were written regularly and contained detailed information about the residents. Residents were seen to be involved in daily living and living an independent life style. There is a policy and procedures on confidentiality at the home. Staff spoken with were aware of the importance of confidentiality and managing information about residents appropriately. Residents use their own rooms or the lounge in the annexe to have meetings in private. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15, 16, 17 Opportunities are available for all residents to be involved if they choose in formal/ informal, internal/ external activities, and are supported by the staff to access their local community and maintain contact with their family and friends. Residents receive a varied and appealing diet, which meets their requirements and choice. EVIDENCE: Care plans seen evidenced that weekly activity programmed for residents were available, currently two residents attend the local “Rethink Centre” and one resident attends Adult Education classes. The majority of the remaining residents living at the home are motivated to organise their own daily activities. All the residents are supported by staff to access the local town centre for personal shopping trips and other interests within the community. Residents leisure activities include listening to music, drawing and painting, playing golf, relaxing in the smoking rooms, some go out for pub lunches. Family and friends are made feel very welcome and there are opportunities at the home for residents to go out and make friends. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 11 During the course of the inspection residents were seen, relaxing in their own rooms, listening to music, sleeping, some were involved in conversation with staff, some were on the smoking room. Three resident spoken to said that they were happy living at the home and expressed satisfaction with home and staff and said that they were friendly and supportive. The weekly menu is made up by the requests of the residents, the kitchen is accessible to the resident to make their on breakfast, drinks and snacks throughout the day. Lunch and the evening meals are provided by the staff. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 The home has good systems in place to meet the resident’s healthcare needs. Staff supports residents who became ill, with dignity and respect. EVIDENCE: Residents access and receive support from a variety of healthcare professionals and services within the local community. Staff would continue to support residents who became ill: residents have expressed that they would prefer to stay at home and be cared for by staff if they became ill. The manager of the home stated that, at the point that an ill resident needs become too complex to be met by the home, the resident would be re-assessed and moved to a more appropriate placement. i.e. respite or hospital. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a clear complaints procedure and Adult Protection policy and procedure available. Not all members of staff have completed P.O.V.A. training. EVIDENCE: The complaints procedure was seen displayed in the lobby/ reception area and is accessible to the residents, the manager said that the plans to re-write the procedure in a more simplistic way enabling the residents to have a better understanding of the process. Residents living at the home appeared to have a good relationship with staff and all have their own individual key worker who they raise issues with. The manager confirmed that most of the residents are quite verbal and so raise issues and would put a complaint in writing if they were not happy at the home. On inspection of a sample of staff training records, several members of staff undertake conflict managements training but not all members of staff have received P.O.V.A. training. Four new members of staff are currently undertaking T.O.P.P.S training and awaiting their certificates. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Furnishings and décor of the premises remain to a high standard and residents live in a homely comfortable which suits their needs and lifestyles. EVIDENCE: The bedrooms in the home and the annexe have all been refurbished, have new carpets and are decorated to a high standard. Residents rooms were seen to be individually personalised and decorated to their personal choice. There were sufficient toilets and bathrooms at the home and annexe to meet residents individual needs. Ample communal space is available at the home and annexe which include a well furnished comfortable lounge and conservatory, a large comfortable lobby/ reception area, smoking lounge and music room. These areas were all seen to be recently redecorated and new flooring fitted. The manager said that new furniture and curtains have been ordered and should arrive this week. Planned improvements the kitchen and dining area are to start this week. A health and safety issue was highlighted at this inspection, recent theft which took place at the home raised issues concerning the security of the building and the annexe. Since the theft sensor lighting has been installed in the front entrance of the home and annexe and the manager is carrying out a risk assessment on the home and annexe and writing an instruction for the staff. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Staffing levels at the home are appropriate for the needs and numbers of resident living at the home. EVIDENCE: The standard of recruitment practices within the home, are satisfactory and offer protection to the residents. Support staff at the home are trained and experienced to do their job and are supervised regularly. Since the last inspection, improvements have been made and sound recruitment practices are in place. Four new staff have been appointed and thus ensures that the staff team no longer work excessive hours. The four staff files examined of the four most recently employed staff, all contained the required information and a five year work history. All staff have completed mandatory training and regular up-dates take place. The registered manager remains committed to providing regular training for support staff. Two staff members spoken to said that the manager is very supportive and approachable and that training and supervision take place. The manager said that eight support staff are currently waiting conformation of continuing NVQ training with an alternative training company, as their original company ceased training. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 The manager is competent and experienced and is currently undertaking the NVQ 4 Registered Managers Award. The home is well managed and run in the best interests of the residents. EVIDENCE: The registered manager has worked at the home for several years, she has appropriate training and is NVQ level 4 Registered Managers Award. A residents questionnaire is in place, and covers specific areas of the care provided at the home, this questionnaire of completed yearly by residents with the assistance of their keyworkers, issues arising from the questionnaires are discussed and dealt with by staff. A summary of these issues and findings should be forwarded to the C.S.C.I. Although the provider of the home is very involved in the running of the home and visits the home must days, regulation 26 monthly reports have not been completed and the Commission has not received any copies. This issue was discussed with the manager. Under this regulation reports must be devised, completed and forwarded to the Commission each month. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 17 A sample of policies, procedures and records seen were appropriately documented and accessible to staff with clear instructions. The home has seen to be currently safe, clean and well maintained. An issue already raised earlier in the report concerning the safety of the premises, highlighted the importance of carrying out a risk assessment on the security of the building, and providing clear instructions to all staff on how keep the home and annexe safe at all times. Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 X 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 3 3 2 3 3 2 3 Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 19 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. 2. Standard YA23 YA41 Regulation 13(6) 26 Requirement Ensure all staff receive P.O.V.A. training Reports under this regulation are devised, completed and forwarded to the Commission Timescale for action 10/08/06 10/08/06 3. YA42 12(1)a) The Registered Manager must 13(4)(a,a) ensure security of the premises and endure the security of the service users based on assessment of their vulnerability and any unnecessary risks to Health and Safety of services users are identified and as far as possible eliminated. 10/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cumberland Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Lodge DS0000015430.V281498.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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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