Inspection on 20/06/05 for Cumberworth Lodge

This inspection was carried out on 20th June 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 but made no statutory requirements on the home.

Other inspections for this house

Cumberworth Lodge 03/10/07

Cumberworth Lodge 19/10/06

Cumberworth Lodge 07/02/06

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 North Lincs DN9 2NB Lead Inspector Kate Emmerson Unannounced 20th June 2005 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 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 J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cumberworth Lodge Address Graizelound Haxey Doncaster North Lincs 01427 752309 Telephone number Fax number Email 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 Care Home 22 Category(ies) of DE(E)(5), OP (22) registration, with number of places Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To create a secure garden area to allow the service users DE(E) category to have access to a safe out door space. Date of last inspection 16 February 2005 Brief Description of the Service: Cumberworth lodge is situated in a quiet lane in the village of Graizelound near Haxey. The accommodation has been extended over recent years and the proprietors continue with their development programme. 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 Dementa who are over sixty five years of age. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 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 June 2005. 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 proprietor and 2 of the staff working in the home at the time of the inspection. The inspector also spoke to 5 people who lived in the home. At the time of the inspection the weather was very hot and the majority of people living in the home were very tired and not did not feel like speaking to the inspector. 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 and 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 home was checked to see if it was kept clean and tidy. What the service does well: The home was clean and tidy and well decorated. There was lots of space and different places to sit. The residents said that they enjoyed the meals and that there was always a choice for every meal. Staff were very good at assisting people who needed help when eating and spent time helping one person at once. Training for the staff was given on a regular basis and care staff had had a wide variety of training to help them do their job safely. The residents said that the staff were good and were kind and polite to them 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. The residents said the staff were very good and did anything they could for them and made their family and friends feel welcome. 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. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 6 The residents said that activities were available to suit people’s needs and staff spent time with the residents playing games or taking them out. Families were invited to events in the home. The person who owned the home and the manager were in the home most days and the residents said that they were able to ask them anything and would feel comfortable to tell them if they ever had a complaint. What has improved since the last inspection? 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 Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 7 contacting your local CSCI office. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 The service users had access to information about the home and the services provided. Service users needs were assessed prior to admission to the home. EVIDENCE: At the last inspection the service users guide contained the information as listed in Regulation 5. However to meet this standard service users views still need to be included in this document. The manager stated that work towards meeting this standard had commenced and he was compiling the information to add to the document. A statement of purpose had been developed and met the standard at the last inspection. A basic pre-admission assessment format had been developed which was completed on referral or at the first visit to see the service user. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 10 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 Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The service users health, personal and social care needs were detailed in individual care plans. There was evidence that the service users health needs were met. EVIDENCE: A random selection of three care plans was examined. There had been continued development and 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 maintained. The care plans had generally been consistently evaluated on a monthly basis and updated as needs changed. There was evidence that the care plans were reviewed as part of the staff supervision process. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 12 There were some very minor deficiencies. One care plan had not been updated in May 05 and Key workers had not always maintained their records consistently. One care plan did not adequately detail the support required where that service user had memory impairment. 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. The care plans in this area need to be more detailed in respect of the care required. In one case the care plan was limited to information on equipment required. 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 had an accident were recorded. There was evidence that the service users had access to regular chiropody services, that equipment for the relief of pressure was provided and there was evidence of advice sought from the continence advisor and the care provided to promote continence in care plans. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 15 The service users were able to choose the lifestyle they wish in the home and were able to exercise choice and control over their lives. Family and friends were welcomed into the home and were included in social events. The meals provided were of good quality with a variety choice for the service users. EVIDENCE: Although there was a limited formal plan of activities relating to monthly social evenings and a church service every third Monday of the month, there was evidence from observation of staff interaction during the inspection and records that staff sat and spent one to one time with service users on a regular basis. The staff member who had responsibility for activities in the home stated that there was little interest from the service users in daily-organised events. The service users confirmed this and stated that there was ‘enough for them’ or that they ‘liked it quiet’. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 14 There was a variety of communal space for the service users to enjoy. On the day of the inspection staff were playing cards with one service user in one room, others were watching Wimbledon in another and others were able to sit quietly reading or having a nap in another room. The gardens were accessible and there was a covered area and seating for the service users. Service stated that their visitors were welcomed to the home and the staff said that family were invited to events ion the home. A regular newsletter was provided to service users and families. The home has cordless and pay phone in the home and personal telephones could be fitted and two of the service users had these. The service users stated that they had a choice in their daily routines and when they got up and went to bed. Regular 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 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. 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 J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 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. EVIDENCE: There was a well-developed policy and procedure with time scales in place. The Commissions address was included in the procedure. The policy and procedure was provided to all service users in an information pack on admission and was displayed in the entrance hall. 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 on an almost daily basis. There were no complaints recorded since the last inspection and the manager audited the records quarterly. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19. 22 and 26 The home was clean tidy and well maintained. There was sufficient equipment provided for service users needs to be met. EVIDENCE: The home is situated in a quiet lane in the village of Graizelound near Haxey. The accommodation has been extended over recent years and the proprietors continue with their development programme. The home provided a variety of accommodation between the older part of the home and the new extensions, which vary in quality of finish and decoration. The proprietor has 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. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 17 Although there was evidence of continuous refurbishment no written records or plan were available at this inspection. The gardens were extensive and reasonably maintained. Seating areas were provided for service users. As a condition of registration, following recent changes to the homes registration, the home must provide a secure garden area. The manager had plans to show how this was to be achieved. There was no documentary evidence that there had been an assessment of the premises and facilities in order to ensure that the recommended equipment is provided. However there was no indication that service users needs were not being met through lack of appropriate equipment during the inspection. 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 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. There were no sluicing facilities provided in the home. Policies and procedures for infection control were in place and staff training had been provided. There was documentary evidence that the services and facilities had been checked to ensure compliance with Water Supply (water fittings) Regulations 1999. . Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Although the home provided staff at sufficient levels to meet the service users needs the use of new staff together on rotas prior to induction training may put the service users health, safety and welfare at risk. The home now must use the Residential Forum guidelines to determine staffing levels. Staff recruitment practises did not provide adequate protection for the service users. There was a training programme in place but the records for induction training were not adequate to provide evidence that the staff had received training for their role. EVIDENCE: Following recent changes to the registration of the home the staffing levels must now be assessed using Residential Forum guidelines. The inspector provided advice as to the use of the system. At the time of then inspection the home had eighteen service users accommodated. The proprietor stated that the home provided four staff on duty during the day and two at night. 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. The staff had varied opinions about the staffing levels and whether these were adequate. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 19 The manager covered approximately 5 short shifts on the floor per week as well being a part time District Nurse. Her husband, the proprietor and a training coordinator supported her in her role and provided assistance on the floor as required. The service users stated the staff were ‘very nice’ and ‘kind’. The home had had some problems with recruitment and had used an agency to recruit staff from abroad. Their papers showed that they were experienced carers with reasonable English language skills. The home had employed staff before Criminal Record Bureau checks or a POVA first check had been completed. The proprietor stated that the staff were completing induction training only and had not worked with the service users alone. The staff rota would not support this showing that the staff were part of the rota and two new staff had worked together on a shift. This does not afford adequate protection for the service users and further breaches of this regulation may lead to enforcement action. 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. There was still a very poor response from staff to NVQ training despite financial support and financial incentives for completion of NVQ training. The proprietor was trying to address this with training contracts for the staff. Five of the sixteen staff had NVQ 2 and two were registered to commence the training. The recently recruited staff from abroad had records to that would indicate that they were qualified nurses and one had records to state that she was a Doctor of Psychology. The home must demonstrate that these qualifications are equivalent to NVQ level 2 to be counted towards the 50 qualified care staff figure by 31 December 2005 A training programme had been developed which provided for staff to receive mandatory training in first aid, fire safety, manual handling, and infection control and food hygiene and to keep these up to date. The proprietor stated that staff were undertaking TOPPS induction training although there was no documentary evidence in the home in terms of the individuals work books. The home had purchased a system to make induction easier to record but these had not been implemented. However there was evidence that some staff had attended the college for basic elements of the induction training. The staff interviewed stated that the more recent care staff had been very experienced but were still shadowed until thought competent by senior staff although they were not requested to evidence this in any way. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 20 There were no staff on the TOPPS foundation training at the time of inspection. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 36 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 does have a system to monitor the quality of the service in the home but this has not been maintained. The home had suitable accounting systems in place. The home does not handle any of the service users money. The staff had not received supervision at appropriate intervals. EVIDENCE: Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 22 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 a experienced training coordinator supported her in her role. The home did have a quality assurance system in place and there was evidence of audits in place up to April 2005 but there had been no further work on this due to the responsible staff member’s sickness. The home had achieved the Investors in People Award in May 2005 and was working towards the Local Authority Quality Assurance Gold Award. The home had suitable accounting systems in place and audited accounts were available. A financial and business plan had not been developed at the time of inspection this was to be completed by 1 July 2005 to meet timescales set at the previous inspection. The home did not deal with any of the service users finances. There was evidence of current insurance displayed in the home. There was evidence that supervision was being completed but that this was inconsistent, the staff confirmed that supervision had been irregular and that they had not had six supervision sessions over a twelve-month period. Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 2 x 3 2 x x Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 24 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 OP29 Regulation 19 Requirement The registered person must ensure that CRB checks are completed for all staff prior to employment in the home. The registered persons must ensure that records of induction training are available for inspection. (Previous timescale – with immediate effect - was not met) The registered person must ensure that staff are undertaking training in sufficient numbers to ensure a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved. The registered person must ensure that the manager has achieved NVQ level 4 in management and care. The registered person must ensure that the quality assurance systems are maintained. The registered person must ensure that staff receive regular supervision at least 6 times per year. The registered person must develop a financial and business Timescale for action With immediate effect With immediate effect 2. OP30 18(1) 3. OP28 18(1) 31 December 2005 4. OP31 10(3) 9(2)(b) 35 31 December 2005 31 September 2005 31 September 2005 1 July 2005 Page 25 5. OP33 6. OP36 18(2) 7. OP34 25 Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 plan. 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 OP1 OP22 Good Practice Recommendations The registered person should include service users views in the service users guide. The registered person should provide evidence that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. The registered person should develop a refurbishment plan and maintain records of maintenance work completed. The registered person should provide sluicing facilities. The registered person should extend the bedroom that is under 9.3 square metres. 3. 4. 5. OP19 OP21 and 26 OP23 Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 26 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cumberworth Lodge J54 Cumberworth Lodge S2912 V233365 20.6.05.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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