Inspection on 19/10/06 for Cumberworth Lodge

This inspection was carried out on 19th October 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 but made no statutory requirements on the home.

Other inspections for this house

Cumberworth Lodge 03/10/07

Cumberworth Lodge 07/02/06

Cumberworth Lodge 20/06/05

Cumberworth Lodge 16/02/05

Cumberworth Lodge 26/08/04

Cumberworth Lodge 24/02/04

Cumberworth Lodge 26/11/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Cumberworth Lodge Graizelound Haxey Doncaster South Yorkshire DN9 2NB Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 19th October 2006 09:30 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 Cumberworth Lodge DS0000002912.V317992.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. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberworth Lodge Address Graizelound Haxey Doncaster South Yorkshire DN9 2NB 01427 752309 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 Maheslall Boodhoo Mrs Rajkumari Boodhoo Mrs Rajkumari Boodhoo Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To create a secure garden area to allow the service users in this category to have access to a safe outdoor space. (Condition met) 7th February 2006 Date of last inspection Brief Description of the Service: Cumberworth lodge is situated in a quiet lane in the village of Graizelound near Haxey. The home provides a variety of accommodation between the older part of the home and the new extensions, which vary in quality of finish and decoration. All the service users are in single accommodation some of which have ensuites. The accommodation is spacious comfortable and homely. The home is registered to accommodate up to twenty male/female service users within the category of old age, not falling within any other category including five service users with Dementia who are over sixty five years of age. The current scale of charges is £312 - £345 per week. There are additional charges £5 -£15 for hairdressing and 310.50 for private chiropody services. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in October 2006. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the provider and the manager and the staff working in the home at the time of the inspection. The inspector also spoke to people who lived in the home. Prior to the inspection nineteen service user surveys were sent out of which fourteen were returned, twenty three staff survey were sent of which seventeen were returned, one health care professional survey was sent and was returned and nineteen relative/visitor surveys were sent of which eleven were returned. Overall the comments were positive about the service e and the care provided in the home. Some of the records kept in the home were checked. This was to see how the people who lived in the home were being cared for, that staff were safe to work in the home, that they had been trained to their job safely and to make sure that the home and the things used in it were safe and were checked regularly. The inspector also looked around the home to see if it was kept clean and tidy. Generally the home continued to provide good care for the service users and the way information had been recorded by the management had been improved and generally kept up to date. What the service does well: The home was very clean and tidy and well decorated. There was lots of space and different places to sit. The staff were very friendly and knew about the care the residents needed before they came in because a staff member always visited people before they arrived at the home. The care people needed was written down and checked often by the staff to make sure that there had been no changes. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 6 The food provided in the home gave plenty of choice and was enjoyed by the service users. One service user commented that they ‘really enjoy’ the meals at the home. Another commented that the food ‘food was very good and there was plenty of it’. The management was keen to provide a good service and took complaints seriously. The provider had a good relationship with the service users and went to speak to them almost every day. One service user commented that ‘if anything causes a problem it is dealt with straight away’. The staff were keen to provide stimulation and activities for the service users and service users generally enjoyed what was on offer in the home. Visitors were made to feel welcome in the home and were involved in the running and development of the home. The home had enough staff in the home at any one time to make sure everyone could be cared for and the residents said that the staff always came when they rang their bell. There were sufficient staff on duty to meet the needs of the service users. the recruitment of the staff was thorough and all the checks to make sure they were safe to work in the home were completed. The management were very keen to make sure that staff were trained to meet the service users needs safely. They provided lots of different types of training on a regular basis. The management were keen to improve the home and asked the service users regularly about the quality of the care in the home. They had achieved a gold Award in the Local Authorities Quality Development scheme. The management generally made sure that the services they provided were safe and had had equipment regularly safety checked. What has improved since the last inspection? They had made sure that everyone had a care plan developed to show how service users needs were to be met. Where risks to the resident’s health or safety had been assessed, the care plans were more detailed to show how they were going to reduce the risks. They had had regular meetings with staff to make sure that they are carrying out their work as expected and to see if there is any more training the person needs. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 7 They had made sure that they checked the quality of the care given in the home and had records that this has been done. They had made sure that all the staff have received updates in training in most areas regarding working safely and made sure that the records were available for inspection. They had made sure that all equipment in the home had been serviced when it is due and provided evidence of this. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cumberworth Lodge DS0000002912.V317992.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 Cumberworth Lodge DS0000002912.V317992.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): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users had access to detailed information about the home and the services provided. There were some minor adjustments to be made to fully meet the standards. Each service user had a copy of the terms and conditions/contract with the home. Service users needs were assessed prior to admission to the home. EVIDENCE: Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 10 The service users guide was detailed and contained the information as listed in Regulation 5. However to meet the National Minimum Standard service users views had still to be included in this document. The provider stated this had been completed but it was not present in the document provided to the inspector dated August 2006 and he was unable to locate the information at the time of the inspection. Prior to writing this report a copy of the information relating to service users views which is to be included in the service users guide was provided to the Commission. A statement of purpose had been developed and was detailed and informative. However the document did not list individual room sizes as required. In terms of range of needs that could be met in the home there was no reference to the homes registration for five service users with dementia and how their needs would be met in either the statement of purpose or service users guide and this must be included. Care must be taken to ensure information in documents is consistent for example the Commissions contact telephone number is different throughout the documents seen. A basic pre-admission assessment format had been developed which was completed on referral or at the first visit to see the service user. A format for recording assessment on admission provided in-depth information on the service users care needs, risks to health and welfare and identified levels of dependency. There was evidence that assessments were further developed during the first few weeks after admission. Two service users who had been admitted just prior to the inspection had detailed assessments completed and the information gathered at assessment had been developed into comprehensive care plans. There was evidence that assessment was ongoing and care plans had been updated where needs had changed. Where service users were funded by Social Services, copies of Care Management assessments and care plans had been obtained. Cumberworth Lodge DS0000002912.V317992.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users health, personal and social care needs were detailed in individual care plans. One action plan had not been adequately risk assessed. There was evidence that the service users health needs were met. The staff had been proactive in requesting medical intervention as required. The policies and procedures supported the safe handling of medication in the home although in one case staff had been making medication administration decisions outside their competency, which may put service users at risk of inappropriate medication administration. The staff respected service users privacy and dignity. EVIDENCE: Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 12 A random selection of three care plans was examined. There had been improvement this area and the care plans were generally informative, well organised and consistent. A format had been developed to provide in-depth information of service users health and care needs and how these would be met. Consistency in the completion and detail of the assessments and care plans examined had been improved. Even in two cases where service users had been admitted just prior to the inspection there were detailed care plans in place. There was evidence of regular monthly evaluation although the way one care plan had been developed meant that some areas were not evaluated for example issues relating to behavioural problems of one service user were identified in a risk assessment and an action plan was in place but as a separate specific care plan had not been completed this area had not been evaluated. Where the above service user had been identified as at risk of wandering and the management had not adequately risk assessed the control measures in place. Use of door handles placed upside down on the bedroom door may deemed as a form of restraint and may put the service user at risk in the event of a fire. Such interventions should not be used without consultation and agreement with all parties involved in the care of the service user such as relatives, social services, psychiatric nurse/consultant and GP. The provider was requested to review this situation as soon as possible and the Commissison has received confirmation that the handles were removed and the service user had been medically reviewed. Risk assessments were completed for areas such as moving and handling and risk of falls. There was evidence that the service users were involved in the development of their care plan and that they or their representative had agreed to it. There was evidence that care plans and recording of outcomes regarding the health care needs of the service users had continued to improve. There was evidence that risk assessments of service users developing pressure sores were completed and care plans developed. There was evidence that risk assessments for nutrition were being completed and evaluated. Diet and weight were being monitored and seated scales were provided. The daily reports on service users health and well-being were detailed and follow-up actions where service users had previously been reported as ill or Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 13 had an accident were recorded. There was evidence of timely interventions where medical advice was required. There was evidence that the service users had access to regular chiropody services and that equipment for the relief of pressure was provided. Records for medications were generally well maintained and ensured a clear audit trail. Senior staff were responsible for the administration of medication and had received accredited training in the safe handling of medication. However it was noted in one case that Zopiclone medication had been prescribed as two to be taken at night but only one was generally administered and the other had sometimes been given earlier in the day. The manager stated this was because the service user sometimes became agitated and this was given to settle them. The medication was not prescribed for use in this way, there was no management plan to support this action or a record of any discussion with the GP to evidence that this had been agreed. The records where the medication had been given earlier didn’t indicate how much medication had been given or indicate a time of administration. The care staff are not qualified to make decisions regarding administration of medications on an as required basis to modify behaviour. There was evidence that the home had requested a review of the service users health and they were due to attend an outpatient’s appointment the following day. The Commission has received confirmation that the above service users medication was reviewed and the home now has Community Psychiatric Nurse support. Evidence from discussions with service users and staff confirmed that the arrangements for the delivery of care in the home ensure that service users privacy and dignity were respected. The service users all occupied single rooms and had the use of telephones in private and were enabled to have phones in their own rooms. Cumberworth Lodge DS0000002912.V317992.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were generally proactive at providing stimulation and activities for the service users and service users felt generally that there were activities that were suitable for them. However there was limited planning and recording of activities provided which must be improved. The home encouraged visitors into the home and involved them in the running of the home. Service users were encouraged to exercise control of their lives and were offered choice in all aspects of daily routines in the home. Meals were provided to meet individual’s needs and preferences and service users enjoyed the meals. EVIDENCE: Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 15 The provider stated that one staff member coordinated the activities in the home. She provided activities twice a week and the other staff provided activities at other times. There were activity plans completed up to August 2006 showing a varied programme. Service users surveys had been completed and there were records of individual interests. However these had not been maintained and records had not been completed for more recently admitted service users. Staff were able to discuss with the inspector the type of activities that were available each day but records of these activities were not always completed. The service users gave varied comments regarding activities, two said there were always activities for them, five said there were sometimes activities they could join in with and five said there were usually activities they would be interested in. There was evidence that the home enables service users to celebrate significant events in their life and one couple had recently had a 60th wedding anniversary party in the home. There was a variety of communal space for the service users to enjoy. On the day of the inspection, in one room service users were playing a game; in another they were watching television, whilst in another service users were reading or having a nap. When two service users were playing a game with staff in one lounge, two of the service users who normally sit in there had become agitated and wandered from the area. The staff stated that this was because they don’t like the noise but there had been little intervention to direct them the quieter areas of the home. Other service users preferred to live their lives separate to the main hustle and bustle of home life and were able to take meals in their own rooms or in quieter areas of the home. The gardens were well tended and accessible and there was a covered area and seating for the service users. There was also an area of the garden off the conservatory where service users were safe to wander outdoors freely as the garden was enclosed. Service users stated that their visitors were welcomed to the home and the staff said that family were invited to events in the home. Visitors stated that they had access to a private area to meet with their relative. A regular newsletter was provided to service users and families and families were invited to be involved in the running of the home through the quality circle meetings open to service users and relatives. Regular four monthly meetings were held for the service users and their families where discussion on the service users comments about the service, homes development and future events were held. The home had cordless and pay phones in the home and personal telephones could be fitted in bedrooms. The service users stated that they had a choice in their daily routines and when they got up and went to bed and in the meals provided. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 16 The service users said that they enjoyed the food and had a variety of meals provided, they said there would be an alternative provided if they didn’t like what was on offer. One service user commented that they ‘really enjoy’ the meals at the home. Another commented that the food ‘food was very good and there was plenty of it’. Menus were reviewed 3 monthly with service user involvement and the menus were a standing item on the agenda for meetings. The day’s menus were displayed on blackboards in two separate areas for the service users. A 3-course lunch was provided daily. Hot choices were available at teatime as well as lunch. Meals for individuals with special dietary requirements, such as soft diets, were met in an appropriate manner. Meals were served at regular intervals although times could be flexible to individuals needs. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 17 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a robust and accessible complaints procedure. The registered persons made themselves available in the home on a daily basis and had a good relationship with the service users. Service users were protected from abuse. EVIDENCE: There was a well-developed complaints policy and procedure with time scales for resolution in place. The Commissions and the Local Authorities Complaints officer address and contact number was included in the procedure, however the telephone numbers in the complaints leaflet were the wrong way round. The policy and procedure was provided to all service users in an information pack on admission and was displayed in the entrance hall. A comments box was also provided. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 18 Service users spoken with stated they had not had cause to complain and stated that they knew who to report to if they had a compliant and would feel comfortable approaching the registered persons with any concerns. The registered persons were observed to have a positive relationship with the service users and their families and they spoke to service users almost daily. One service user commented that ‘ this is an extremely good home and I am happy and contented here’. ‘The care and support are very good’. Another commented that ‘if anything causes a problem it is dealt with straight away’. There were no complaints recorded since the last inspection and the manager audited the records quarterly. A copy of the local authority policy and procedure for the protection of vulnerable adults was available in the home and there was an in-depth policy and procedure for the home that linked to this. Policies and procedures had been developed for protection of service users in the management of physical and/or verbal aggression and restraint and managing service users money and financial affairs. Staff training had been provided in the protection of vulnerable adults and there was evidence that this was part of a rolling training programme and was included in induction training. Recruitment had improved and there was evidence that all appropriate checks were completed before staff commenced work in the home. There had been no allegations of abuse in the home. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 19 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): 19, 20, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and well maintained. There was sufficient equipment provided for service users needs to be met. There were some deficiencies that may be a risk to service users health and welfare. The provider had taken prompt action in one area had provided written evidence that one of the issues had been addressed immediately. EVIDENCE: The home is situated in a quiet lane in the village of Graizelound near Haxey. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 20 The accommodation had been extended over recent years and the proprietors continue with their development programme. To this end the proprietors had ceased use of two rooms in the older part of the building on the second floor until these had been refurbished. The shower room on the third floor and the bathroom on the first floor had been completed. Room 8 on the third floor had been refurbished and a new carpet had been fitted in the corridor of the old part of the building. The exterior of the older part of the property had been repainted since the last inspection. New carpets had been fitted in two bedrooms and where these were occupied the service users had had input into the colour of the carpet provided. A refurbishment plan and records of maintenance work had been completed. The proprietor had decided to change the use of some bedrooms rooms from doubles to singles so all the service users were in single occupancy accommodation some of which had ensuites. The accommodation was spacious comfortable and homely. The gardens were extensive and reasonably maintained and provided a fenced area of the garden that could be freely accessed from the home. Seating areas were provided for service users. There was a passenger lift and a chair lift in the older part of the building to the upper floors. There were handrails in the corridors and toilets. The home provided one bath hoist, an electrical hoist for transferring service users who are unable to stand and one portable mechanical moving and handling aid that would assist a service user to a standing position. A partial tour of the home was conducted as part of the inspection and the home was clean and tidy and odour free. One service user commented that there ‘was no dust in the corners’. The majority of the service users stated that the home was always fresh and clean the others stated that it was usually fresh and clean. Radiator guards and window restrictors were provided through out the home to maintain service users safety. Exterior doors through out the building had been alarmed to minimise the risk of service users going out unaccompanied where they were not safe to do so. Hot water temperatures at outlets checked were within acceptable ranges. There were some deficiencies, which will need to be addressed to ensure that service users health and safety is not compromised.. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 21 The kitchen was exceptionally clean and tidy and all appropriate records were clearly maintained. Two kitchen cupboard doors were missing but the provider stated that the units were to be replaced with aluminium shelving in November 2006. One of the service users families had purchased a freestanding electric heater. The temperature of the heater was unable to adequately controlled to a safe level and the service user and this may put the service users health and safety at risk and may be a fire hazard for the home. The proprietor was asked to complete a risk assessment and ensure that this is safe for use. The provider must put systems in place to ensure that this situation does not arise again in future. One service user had a reversed door handle to discourage wandering the provider was advised that this could be a form of restraint and a fire hazard. At the time of writing the report the provider had confirmed in writing that the handles had been removed immediately following the inspection. The service user also had an alarm mat to alert staff that the service user had wandered from the bedroom; this was not adequately secured and could be a trip hazard. The wooden fire escape had a couple of boards that required replacement as they had started to deteriorate. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 22 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided sufficient care staff hours to meet service users needs. Recruitment procedures had continued to be improved and provided adequate protection for the service user. The providers and staff were committed to improvement and developing their skills. Induction training and planning to ensure mandatory training had improved although more care must be taken to ensure that mandatory training is kept up to date in future. EVIDENCE: At the time of the inspection the home had nineteen service users accommodated. The provider used the residential forum to assess staffing levels and at the time of the inspection he was providing 434 care hours. The proprietor stated that the home provided four staff on duty in the morning shift and three during the afternoon/evening and two at night. Although not counted in the care staff numbers the manager worked approximately 5 short shifts on the floor per week as well being a part time Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 23 District Nurse. Her husband, the proprietor and a training coordinator supported her in her role and provided assistance on the floor as required The staff rotas showed and the staff confirmed that the home provided between three and four care staff on the morning shift and two or three in the afternoon with an activities coordinator working two afternoon shifts per week. The staff had varied opinions about the staffing levels and whether these were adequate and half the staff group stated that they didn’t think there were sufficient staff on duty to meet needs. There were comments that they would like to spend more time sat chatting with the service users. All the visitors who returned comment cards stated that there were sufficient staff on duty and service users stated that there was always or usually sufficient staff on duty and felt they got the care and attention they required. A service user commented that ‘the care is good. Staff are short sometimes but care isn’t neglected’. The recruitment processes had been maintained and improved. There was evidence that home had not employed staff before Criminal Record Bureau checks or a POVA first check had been completed. There were two written references on file. The proprietor had a very positive attitude to training and was the lead partner for North Lincolnshire Training consortium involved in accessing funds from TOPPS for NVQ training and arranging the training. Staff were paid for all training and meetings they attended. Staff were now more willing to attend training and had made good efforts to complete NVQ training. Eleven of the nineteen staff had NVQ 2. Staff were undertaking TOPPS induction training and records were available to evidence this. There was evidence that some staff attended the college for basic elements of the induction training and this was also supported via external training specific to service users needs. Experienced staff who had been employed by the home and had provided evidence of qualifications were provided with an induction to the home and polices and procedures. One member of staff who had just finished their induction stated that they felt well prepared for their role. They stated the standard of care was good and service users came first. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 24 There was evidence that at least half of the staff had not received moving and handling training although this had been identified and training had been arranged for December. The providers were informed that due to the potential risks to service users and the fact that the training manager had already achieved an appropriate qualification to provide this training, staff training must be provided as soon as possible. The provider has provided written confirmation that the staff group have now been provided with up to date moving and handling training. Two senior staff were booked to complete a moving and handling training qualification in October 2006. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 25 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is an experienced nurse who is still practising on a part time basis. She is well supported in her role. She has not yet commenced the NVQ level 4. The home has an effective system to monitor the quality of the service in the home, which involves the service users and all the other stakeholders. They have achieved the Local Authorities Gold award in their Quality Development Scheme. The home does not assist with service users finances. Staff had regular supervision meetings with their manager. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 26 There was evidence that staff and service users health and safety through safe working practises was promoted. EVIDENCE: The manager is an experienced nurse who continues to practise on a part time basis. She is well supported in her role. She has not yet commenced the NVQ level 4. The proprietors were considering employing a manager, as she did not wish to undertake this qualification. Her husband who is also the proprietor and an experienced training coordinator supported her in her role. The training coordinator has commenced the NVQ 4 in management and care. The home did have a quality assurance system in place and there was evidence of audits in place up to August 2006. The management had met the majority of the requirements and recommendations from the last inspection. Service user-friendly questionnaires had been developed and implemented and visitors and staff had been surveyed for their views on the service. Action plans had been completed following evaluation of responses. A newsletter was provided every three to four months. The providers enabled the staff, service users and visitors to be involved in the running of the home and care staff meetings were held two monthly and senior staff meetings monthly. The visitors and service users had a meeting quarterly. Quality circle meetings were also held to discuss specific outcomes form surveys and action planning and two had been held since the last inspection. Staff were paid for all training and meetings they attended. The home had achieved the Local Authorities Gold award in the Quality Development Scheme in August 2006 and the Investors in People Award in May 2005. As part of the quality audits the complaints were audited every quarter and accidents were monitored monthly. The home encouraged service users to manage their own finances and at the time of the inspection the provider stated they were not assisting any of the service users with finances or holding any money on their behalf. There was evidence that the staff were now regularly supervised and records were maintained. There was evidence that staff and service users health and safety through safe working practises was promoted. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 27 There was evidence that staff had received mandatory training in fire safety, food hygiene and infection control. At the time of the inspection at least half of the staff group had not received up to date moving and handling training. At the time of writing the report the provider had sent written evidence that this had now been provided. There was evidence that the gas boiler, portable electrical equipment, fire equipment and emergency lights had been serviced. Lifts and hoists had been serviced since the last inspection. All senior staff had completed appointed persons first aid certificates. Emergency lighting had been tested monthly and fire alarms weekly on a consistent basis since the last inspection. Fire drills had been conducted monthly since March 2006 and staff attendance was monitored. The provider stated that the fire alarm and emergency lighting had been serviced on the 29 October 2006 but was waiting for the certificates to evidence this. New fire risk assessments and environmental risk assessments have completed by an external company and the home were waiting their report and action points. The home had very minimal falls/accidents recorded. There was evidence of good falls management in the home and the home was working with the Primary Care team as part of a fall reduction initiative and staff had accessed training in this area. Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 28 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 2 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 4 Requirement The registered person must include in the statement of purpose the range that can be met in the home with reference to the homes registration for five service users with dementia and list individual room sizes. The registered person must ensure that care plans actions will not subject the service user to any unnecessary physical restraint The registered person must ensure that staff are not making medication administration decisions outside their competency and service users placements are reassessed where PRN medication is required to manage challenging behaviour or agitation. (Previous timescale – 1 February 2006 was not met) The registered person must ensure that records of activities are maintained to evidence the programme of activities available in the home. The registered person must DS0000002912.V317992.R01.S.doc Timescale for action 01/03/07 2 OP7 13(7) 19/10/06 3. OP9 14(2) 13(2) 19/10/06 4 OP12 16(2)(n) 01/12/06 5 OP19 23(4) 01/12/06 Page 30 Cumberworth Lodge Version 5.2 6 OP25 13(4) 7 OP25 13(4) 8 OP31 10(3) 9(2)(b) 9 OP38 18(1) ensure that the fire escape is checked and repaired where boards have deteriorated. The registered person must ensure that the freestanding heater is guarded or has a guaranteed low surface temperature. The registered person must ensure that the alarm mat is safely secured so as not to be a trip hazard. The registered person must ensure that the manager has achieved NVQ level 4 in management and care. (Previous timescale - 31 December 2005 and 1 October 2006- was not met) The registered person must ensure that all mandatory training is up dated in a timely manner and future planning must reflect this. 19/10/06 19/10/06 01/03/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The registered person should include in the service users guide the range of needs that can be met in the home with reference to the homes registration for five service users with dementia The registered person should extend the bedroom that is under 9.3 square metres. The registered person should put processes in place to ensure that items are not brought into the home which may cause a hazard to the service user, 2 3 OP23 OP25 Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hessle wood Country Office Park Ferriby Road Hessle HU13 0QF 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 Cumberworth Lodge DS0000002912.V317992.R01.S.doc Version 5.2 Page 32 - 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. 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