Inspection on 17/07/07 for Cumberland Lodge

This inspection was carried out on 17th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cumberland Lodge 06/12/06

Cumberland Lodge 10/02/06

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 Michelle Love Unannounced Inspection 17th July 2007 09:30 Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 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.V345046.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 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.V345046.R01.S.doc Version 5.2 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.V345046.R01.S.doc Version 5.2 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). 6th December 2006 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. The range of weekly fees charged range from £385.00 to £1500.00 per week. In addition to the fees, there are additional costs for residents pertaining to hairdressing, chiropody, toiletries, magazines, newspapers, personal toiletries etc. Upon request, prospective residents and/or their representatives can have access to a copy of the latest inspection report. Cumberland Lodge DS0000015430.V345046.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` site visit whereby all key standards were inspected. The visit was undertaken by Michelle Love, Regulation Inspector and commenced at 09.30 a.m. and finished at 15.00 p.m. At this visit a range of records relating to individual residents (care plan documentation) and support staff were examined (staff recruitment records, induction records, staff training records, staff rosters and staff supervision). Additionally a brief tour of the premises was undertaken and other records relating to the homes medication, arrangements for food/menu’s and health and safety issues were examined. The inspection was conducted with the assistance of the registered manager. At this visit two support staff and four residents were spoken with, however one resident refused to converse/enter into dialogue with the inspector. The inspector understands that people may find the inspection process uncomfortable and intimidating and with that in mind discussions were not pursued. What the service does well: What has improved since the last inspection? What they could do better: Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 6 As highlighted within previous inspection reports, Regulation 26 reports must be completed by the registered provider and be readily available for inspection. This requirement has not been met for some considerable time and must now be addressed. The registered provider/manager must ensure that appropriate staffing levels are maintained at all times, that all records as required by regulation are sought pertaining to staff recruitment and that all staff undertake regular training. Particular attention is drawn to the fact that currently a number of staff working within the care home are administering medication to residents but do not have up to date training and in some cases there is no evidence to indicate that this has been undertaken. Additionally not all members of staff working within Cumberland Lodge have received training relating to Protection of Vulnerable Adults and challenging behaviour. 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 Lodge DS0000015430.V345046.R01.S.doc Version 5.2 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.V345046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good system for assessing the needs of prospective people. EVIDENCE: No new residents have been admitted to Cumberland Lodge for some considerable time. At the time of the site visit the registered manager advised the inspector that the home had one vacancy. As highlighted at the previous inspection to the home the pre admission assessment format continues to be comprehensive. Wherever possible prospective residents are encouraged to visit the care home. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes care planning process is good and reflects individual residents needs and how care is to be provided for individual residents by support staff. EVIDENCE: At this site visit two individual care plans were inspected. Each care plan was observed to be person centred and used as a working document. Each care plan included a comprehensive risk assessment and all aspects of the care plan had been reviewed and updated to reflect individuals’ changed needs. In addition to each care plan, information had been collated relating to individual’s social family history, medical history and psychiatric history. Daily care records continue to be written regularly and contained detailed information about the residents and how they spent their day. No formal reviews by individual resident’s placing authorities have been undertaken for some considerable time. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities are available for all residents to participate in both internal and external activities. Residents receive a varied and appealing diet which meets their requirements and choice. EVIDENCE: Care plans continue to evidence that some residents access and participate within `formal` activities e.g. adult education and local `drop in centre`. The majority of residents residing at Cumberland Lodge continue to organise their own daily activities. Where required, residents are supported by staff to access the local town centre for personal shopping trips and other interests within the community. The Commission have over recent months received several Regulation 37 Notifications detailing occasions whereby residents have returned to the home environment under the influence of alcohol or have been verbally threatening and physically aggressive towards others. Evidence suggests that issues have been dealt with appropriately by the registered manager and support staff. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 11 The home has an `open visiting` policy whereby family members and friends are made to feel welcome. Residents wishes pertaining as to whether or not they wish to meet with their member of family/friend are respected by support staff. During the site visit, residents were observed to relax and spend time in their own room, either listening to music, sleeping, watching television, conversing with others living at the home and with support staff. Other residents were observed to go out independently. Since the last inspection the homes kitchen has been extensively refurbished. The kitchen is very modern and residents spoken with were clearly pleased with the finished result. Residents were observed to have `open` access to the kitchen and to prepare drinks and refreshments as often as necessary. Residents are given the opportunity to contribute ideas and be part of the decision making process, relating to menu planning and shopping. The menus are devised on a weekly basis and continue to offer residents a flexible and varied diet. Alternatives to the menu are readily available and one resident advised the inspector that they are currently on a diet. The resident further stated that appropriate food items are readily available to help them to lose weight and staff are supportive and encouraging. Individual residents spoken with were very complimentary regarding food/meals provided. The registered manager was advised that were alternatives to the menu are provided this should be detailed within the home’s menu book. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that the healthcare needs of individual residents are met by a range of healthcare professionals. Systems for the safe storage, recording and administration of medication were deemed satisfactory and appropriate. EVIDENCE: Residents access and receive support from a variety of healthcare professionals and services within the local community (Consultant Psychiatry, District Nurse Services, Community Psychiatric Nurse, GP etc). The homes medication storage facilities were deemed appropriate. A list of staff names, signatures and initials depicting those staff deemed competent to administer medication was readily available. On inspection of MAR (Medication Administration Records) records, only one omission of signature was observed. PRN (as and when required medication) protocols were devised for all residents. The registered manager advised the inspector that only two members of staff working within the care home do not at this time administer medication to Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 13 residents. It was of concern from inspection of staff training files that not all staff had received training relating to the Safe Administration of Medication or received updated/refresher training, yet staff are administering medication to residents. As a result of this a `Serious Concern` letter was forwarded to the manager following the inspection. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints and adult protection policy and procedure. EVIDENCE: Since the last inspection to the home (6th December 2006) the home has received no complaints. The homes complaints procedure has been amended to reflect that the Commission no longer has any statutory responsibility to investigate complaints. No protection of vulnerable adults issues have been raised since the last inspection. On inspection of individual staff training records, evidence suggested that not all members of support staff working within the care home have received training pertaining to protection of vulnerable adults and/or challenging behaviour. This has been highlighted at previous inspections to the home and must be addressed as a priority. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, safe and comfortable environment which suits their needs and lifestyles. EVIDENCE: Furnishings and décor within the home environment remain to a high standard. Since the last inspection, alterations to the homes physical environment have been undertaken resulting in a newly fitted and refurbished kitchen/dining area and one shared bedroom has been split to form two single bedrooms with ensuite facilities. Resident’s bedrooms continue to be personalised and individualised. The home provides ample communal space, both within the main house and the annexe. No health and safety issues were highlighted at this inspection. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels have not always met the needs of the people using the service. In general residents are protected by the home’s recruitment procedures and practices. Gaps within the home’s training for staff were observed. EVIDENCE: The registered manager confirmed to the inspector that the homes staffing levels are 3 staff daily between 07.30 a.m. and 21.15 p.m. and 2 waking night staff between 21.00 p.m. and 07.45 a.m. On inspection of four weeks staff rosters, evidence suggested on four occasions that there were insufficient staff on duty during either the early or late shift. The registered manager confirmed that no agency staff/bank staff had been utilised to address the shortfall. This is unacceptable and the registered provider/manager must ensure that at all times there are sufficient staff on duty to meet the needs of people residing at the care home. The registered manager was advised that inadequate staffing could restrict the ability of the service to deliver person centred care. The staff rosters also evidenced on occasions some staff continuing to work long days (07.30 a.m. to 21.15 p.m.total of 13.45 hours). Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 17 Since the last inspection one new member of staff has been newly employed. On inspection of their staff employment file the majority of records as required by regulation had been sought, however gaps were noted in relation to no recent photograph, no job description, only one written reference which was received after they had commenced employment at Cumberland Lodge and no evidence of an induction. On inspection of staff training records for all staff, it was clearly evident that there are significant gaps relating to not all staff having training relating to fire awareness, basic first aid, food hygiene, health and safety, infection control, COSHH (Control of Substances Hazardous to Health) and moving and handling. Additionally there was limited evidence to indicate that staff have received training relating to those conditions associated with people who have a mental disorder, for example, the mental capacity act, substance abuse and misuse, schizophrenia, depression etc. Training records also indicate that some training undertaken by staff is out of date and needs to be updated as a matter of urgency. Supervision records were inspected at random for five members of support staff. Evidence indicated formal supervision sessions are being conducted on a regular basis. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced and able to run the care home. EVIDENCE: The registered manager has been at Cumberland Lodge for the past 8 years. As yet the registered manager has not completed the Registered Managers Award but remains committed to achieving this in due course. In general the home is well run and the outcomes for residents are positive, however the registered manager must ensure that issues relating to shortfalls in staffing levels, staff recruitment records and staff training must be addressed to ensure that staff working within Cumberland Lodge are trained, skilled and in sufficient numbers to support the people who use the service. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 19 A quality assurance questionnaire has been devised, however since 2006 these have not been forwarded to seek other’s views. No questionnaire has been devised for support staff and other professionals. It is of concern and disappointing to note that despite a verbal agreement being made with the registered provider to complete Regulation 26 reports bi monthly, these have not been completed despite previous assurances. A random sample of records as required by regulation were inspected pertaining to fire drills, fire risk assessment for the home, emergency lighting and alarm testing, the homes electrical certificate, resident’s monies and a variety of policies and procedures. All of the above were seen to be satisfactory, however the homes gas certificate was out of date/overdue and the homes employers liability certificate had expired in October 2006. The registered manager was advised that a copy of both certificates must be forwarded to the Commission within 14 days of receiving this report. Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 20 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 X 2 3 3 X 4 3 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 1 X X 2 X Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Ensure that all staff who administer medication to residents have up to date training. Ensure that all staff have training relating to challenging behaviour. Previous timescale of 1.6.07 not met. Ensure that at all times there are sufficient numbers of staff on duty. Ensure that the homes recruitment procedures are robust and that all records as required by regulation are sought. Ensure that all staff receive appropriate training to the work they perform and the needs of individual residents residing at the care home. Reports under this regulation are devised and completed bi monthly. Previous timescale of 10.8.06 and 1.2.07 not met. Timescale for action 01/09/07 2. YA23 13(6) 01/10/07 3. 4. YA33 YA34 18(1)(a) 19 21/08/07 21/08/07 5. YA35 18(1)(c) 01/11/07 6. YA39 26 21/08/07 Cumberland Lodge DS0000015430.V345046.R01.S.doc Version 5.2 Page 22 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.V345046.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. 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