Inspection on 17/10/05 for Cumberland Lodge

This inspection was carried out on 17th October 2005.

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 17/07/07

Cumberland Lodge 06/12/06

Cumberland Lodge 10/02/06

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 Mrs Michelle Love Unannounced Inspection 09:00 17 October 2005 th Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 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.V251167.R01.S.doc Version 5.0 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.V251167.R01.S.doc Version 5.0 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.V251167.R01.S.doc Version 5.0 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). 3rd March 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.V251167.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This care home was inspected by two inspectors over a period of four hours. At the time of the inspectors arrival the registered manager was not present but arrived approximately 40 minutes later. During the inspection a number of records and documents were inspected and a tour of the premises were undertaken. Discussions took place throughout the inspection with the registered manager, three members of support staff, the registered provider and several residents. What the service does well: What has improved since the last inspection? What they could do better: Some improvement is required in relation to implementing robust recruitment procedures and ensuring that some members of staff are not working excessive hours i.e. 71 hours per week. Although the registered manager remains committed to providing training for support staff, care must be taken Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 6 to ensure that all staff undertake mandatory courses and receive refresher/updated training on a regular basis. 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.V251167.R01.S.doc Version 5.0 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.V251167.R01.S.doc Version 5.0 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): 2, 3, 4 and 5 Prospective residents are assessed prior to their admission to Cumberland Lodge and individuals have the opportunity to visit the home on a trial basis. EVIDENCE: No new residents have been admitted to the care home since the last inspection. As a result of the resident’s pre admission assessment not being available at the last inspection, documentation was inspected on this occasion. A pre admission assessment was evident, however there was no additional information to support the home’s assessment from the residents community psychiatric nurse, social worker and/or local mental health hospital. The pre admission assessment did not detail the date this was completed. Evidence was available to indicate that the resident had visited the home prior to admission and undertaken a number of trial visits. No contract of residency was available for the newest resident to be admitted to Cumberland Lodge. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 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): 6, 7, 8 and 9 The care planning systems within the home, reflect individual residents needs and detail how care is to be provided by support staff. Individual residents are empowered and supported by staff, to enable them to make daily decisions about their lives and to participate within the daily running of the care home. EVIDENCE: On inspection of two individual care plans/risk assessments, these were observed to be detailed and informative and evidenced residents needs pertaining to social, emotional, physical and healthcare requirements. In addition to the above information, records also included reference to external professional agencies utilised, behavioural indicators and resident’s personal preferences. Risk assessments were evident for the majority of assessed and identified risk, however additional information is required detailing staffs interventions/specific guidelines. Daily care records were observed to be written daily and contained informative information. One resident’s daily care records made reference to an incident which occurred in September 2005, whereby the resident displayed intimidating behaviour towards others living at Cumberland Lodge and support staff as a result of being intoxicated. No regulation 37 notification was forwarded to the Commission. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 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): 12 and 13 Opportunities are available for all residents to participate if they so choose in formal/informal and internal/external activities of their choice. EVIDENCE: Of those care plans inspected, weekly activity programmes for individuals were readily available. Currently one resident is accessing adult education classes and four residents have the opportunity to attend the local `Rethink Centre` if they so choose. All residents are supported by staff, to access the local town centre for personal shopping trips and other interests within the local community. The registered manager advised that group outings have proved very unsuccessful. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 11 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): 18, 19 and 20 Residents receive support from staff as and when required. The home has good systems in place to meet resident’s healthcare needs and to ensure that medication practices and procedures are satisfactory. EVIDENCE: Residents continue to access and receive support from a variety of healthcare professionals and services within the local community. Individual residents are empowered and encouraged to make choices and pursue personal preferences wherever possible i.e. one resident chooses on most occasions to not eat with the other residents and support staff and to have some of his meals in his room. The home’s procedures for the safe administration of medication within the home were seen to be satisfactory and appropriate. The registered manager, was advised to ensure that the list of staff initials/names/signatures needs to be reviewed and updated. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 12 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): 23 The home has robust procedures in place pertaining to abuse and protection of vulnerable adults. Not all members of staff have received POVA training. EVIDENCE: No changes have been made to the home’s adult protection policies and procedures. On inspection of a random sample of staff training records, several members of staff have undertaken conflict management training, however not all members of staff have received POVA training. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 13 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): 24 and 30 Furnishings and décor remain to a high specification and residents live in within a homely and safe environment. EVIDENCE: No health and safety issues were highlighted at this inspection. On inspection of the premises, the bungalow was observed to be in the process of redecoration. The registered person is to meet with the Commission in the future to discuss planned building works to alter the home’s kitchen/dining area and to change one double bedroom into two single rooms for residents. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 14 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): 31, 32, 33, 34 and 35 Staffing levels within the home remain appropriate for the current needs of residents. Not all records as required by regulation relating to staff recruitment are sought/available. EVIDENCE: Rosters inspected evidenced that staffing levels as agreed by the previous registration authority are adhered to and increased according to residents needs. Rosters indicate that some members of staff continue to work long days/excess hours i.e. between 56-71 hours in any one week. The registered manager advised that since the last inspection four new members of staff have been appointed. On inspection of staff files, documentation indicated that not all records as required had been sought i.e. not all files had a CRB, employment history for two member’s of staff not fully explored, some references unclear as to whether these were from the employees last employer, 1x written reference for one person, induction only partially completed for two members of staff, no evidence of training/qualifications for two members of staff, no written health status for one member of staff, no proof of ID for one member of staff and no evidence of visa/immigration status. Training records indicated that some members of staff require refresher/updated mandatory training. It is envisaged that the registered manager will complete NVQ 4/Registered Managers Award by September 2006. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 15 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): None of these standards were inspected on this occasion. EVIDENCE: The registered manager has been in post at Cumberland Lodge for several years. On this occasion no standards pertaining to this section were inspected. A discussion took place with the registered manager and provider in relation to the Commission not receiving any Regulation 26 reports (This has been highlighted at two previous inspections to the home). Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 2 3 2 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 2 2 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cumberland Lodge Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000015430.V251167.R01.S.doc Version 5.0 Page 17 YES Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13(4)(a) (c) 37(e) 13(6) 18(1)(a) Requirement Ensure that unnecessary risks for residents are identified and risk assessments include staff interventions/guidelines. Ensure that the Commission is informed pertaining to this regulation. Ensure that all staff receive POVA training. Ensure that all staff working at the care home are competent and in such numbers for the health and welfare of residents. Previous timescale of 01.07.05 not met Ensure that all records as required by regulation have been sought and are available for inspection. Reports under this regulation are devised, completed and forwarded to the Commission. Previous timescale of 01.07.05 not met Timescale for action 01/02/06 2 3 4 YA6 YA23 YA33 01/02/06 01/05/06 01/02/06 5 YA34 17(2),Sch 4,19, 2 26 14/02/06 6 YA41 14/02/06 Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA32 YA37 Good Practice Recommendations A minimum of 50 of care staff should attain NVQ Level 2 by 2005. The registered manager should attain NVQ Level 4 by 2005. Cumberland Lodge DS0000015430.V251167.R01.S.doc Version 5.0 Page 19 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. 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