Inspection on 07/02/06 for Cumberworth Lodge

This inspection was carried out on 7th February 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cumberworth Lodge 03/10/07

Cumberworth Lodge 19/10/06

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 Unannounced Inspection 7th February 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.V282751.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V282751.R01.S.doc Version 5.1 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.V282751.R01.S.doc Version 5.1 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. 23rd June 2005 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 is registered to accommodate in total up to 22 service users. 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 was spacious, comfortable and homely. The service users have access to large gardens with seating areas these have been further developed to meet the needs of all the service users accommodated. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 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 February 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 acting 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. 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 home was checked to see if it was kept clean and tidy. Generally the home continued to good individualised care but the management systems in the home had not been maintained and there was deterioration in the standard of care planning since the last inspection. What the service does well: What has improved since the last inspection? Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 6 There were records to show that new staff had received training to ensure that they understood their role and worked safely. There were more staff prepared to train for a qualification in care. The home had made sure that all the required checks on staff were done before they started work. 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. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 7 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.V282751.R01.S.doc Version 5.1 Page 8 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 the following standard(s): None of the above standards were assessed at this inspection. Please refer to previous inspection reports for information. EVIDENCE: Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 8, 9 and 10 The standard of care planning in the home had deteriorated and not all service users had their health, personal and social care needs detailed in individual care plans. There was evidence that the service users health needs were met although care plans did not support the care provided. The policies and procedures supported the safe handling of medication in the home although staff were making medication administration decisions outside their competency, which may leave service users at risk of inappropriate medication administration. The staff respected Service users privacy and dignity although lack of curtains in one room did not afford adequate privacy for one service user. EVIDENCE: A random selection of four care plans was examined. Whilst two of these contained detailed assessments and care plans and had been regularly Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 10 evaluated there was deterioration in the standard of care planning noted in the more recently admitted service users files. In one a care plan had not been developed or agreed and in another a very basic care plan had been completed but not agreed. In one of the care plans where a service user had been found wandering some distance for the home on least 4 occasions since admission there was no management plan in place to minimise this risk. (The Commission had not been informed as required under Regulation 37 of these incidents of wandering.) Whilst health needs were met, care plans did not always support the care required. In one case where a service user had been discharged from hospital with pressure sores and had lost weight the care plan had not been updated to show the changes or provide an action plan as to the care now required. There was no management plan in place for the administration of ‘as required medications’ that were to be used to modify behaviour when a service user became agitated or challenging. The care staff are not qualified to make decisions regarding appropriate administration of these types of medications and were advised to contact the GP for a review of the service users medication. If this medication, in the GP’s opinion, is required the service user must be reassessed for a more appropriate placement. All records relating to medication held in the home were well maintained and appropriate stage was provided. Senior staff were responsible for the administration of medication and had received accredited training in the safe handling of medication. 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. However during the tour of the building it was noted that even though there were net curtains to the window in room 5 there were no curtains this did not protect the privacy and dignity of the service user in that room. The manager stated that the staff were instructed on induction and in key worker training regarding respecting privacy and dignity when assisting in care tasks. 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.V282751.R01.S.doc Version 5.1 Page 11 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 the following standard(s): None of the above standards were assessed. Please refer to previous reports for information. EVIDENCE: Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18 Service users were protected from abuse. EVIDENCE: 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 to the majority of staff in the protection of vulnerable adults and challenging behaviour and there was evidence that further training was booked for March 8th 2006. There had been no allegations of abuse in the home. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19 and 25 The service users live in a clean tidy and well maintained home. The exterior appearance of the home could be improved. 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. To this end the proprietors had ceased use of two rooms and the yellow bathroom in the older part of the building on the second floor until these had been refurbished. The shower room on the third floor had been completed but was waiting for floor covering to be fitted before use. 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 paintwork of the older part of the property was in poor condition. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 14 A refurbishment plan and records of maintenance work had not been completed. 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. The gardens were extensive and reasonably maintained. Seating areas were provided for service users. As a condition of registration, following changes to the homes registration, the home must provide a secure garden area. The manager had completed this work and provided a fenced area of the garden that could be freely accessed from the home. 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. 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. The kitchen was exceptionally clean and tidy and all appropriate records were clearly maintained. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 Recruitment procedures had improved and provided adequate protection for the service user although the homes records must be fully maintained. Induction had improved but lack of mandatory training may put service users health and safety at risk. EVIDENCE: There was improvement noted in the recruitment processes. There was evidence that home had not employed staff before Criminal Record Bureau checks or a POVA first check had been completed. However some of the evidence for this was not held in the staff files but was provided by the umbrella organisation at the time of the inspection. Advice was given that records relating to the recruitment of staff must be complete and held at the home. 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. Five of the twenty staff had NVQ 2 and one had NVQ 3. Two care staff had commenced the training for NVQ 2. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 16 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. 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. There were no staff on the TOPPS foundation training at the time of inspection. There was insufficient evidence that staff had received adequate mandatory training at regular intervals to ensure that the staff worked safely and service users health and safety was not compromised. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 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 required management training. The home does have a system to monitor the quality of the service in the home but this has not been maintained. The staff had not received supervision at appropriate intervals. There was insufficient evidence that the health and safety of the service users and staff was being maintained. EVIDENCE: The proprietors/manager of the home were on annual leave at the time of the inspection and Sandra Markham, an experienced manager, had taken responsibility for management tasks during their absence. A deputy manager Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 18 had been employed since the last inspection and was undertaking the Registered Managers Award. 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 since then. The home now had a deputy manager who would be taking responsibility for this in the future. The home had achieved the Investors in People Award in May 2005. There was evidence that supervision had recommenced in January 2006 and all the staff but one had received a supervision session in this period. Records could not be located at the time of the inspection to evidence that supervision had been completed prior to this. There was insufficient evidence that staff and service users health and safety through safe working practises was maintained. There was a lack of evidence that staff had received mandatory training in moving and handling, fire safety, food hygiene and infection control. The last recorded fire drill for the staff was December 2004. There was evidence that gas boiler had been fitted but there was no evidence that the second older boiler had been serviced. There was no evidence that the portable electrical equipment had been serviced and 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. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 19 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X 3 X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 2 X 2 Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 Requirement The registered person must ensure that all service users have a care plan developed which indicates how needs are to be met and associated risks minimised. The registered person must ensure that a Regulation 37 notification is completed and forwarded to the Commission with out delay where an event in the care adversely affects the well-being or safety of the service user. The registered person must ensure that service users placements are reassessed where PRN medication is required to manage challenging behaviour or agitation. The registered person must ensure that curtains are provided to service users private accommodation in bedroom 5. The registered person must ensure that the exterior of the old part of the home is repainted. The registered person must DS0000002912.V282751.R01.S.doc Timescale for action 07/02/06 2 OP7 37 07/02/06 4 OP9 14(2) 13(2) 07/02/06 5 OP10 12(4) 16(2) 23(2) 07/02/06 6 OP19 01/06/06 7 OP29 19 07/02/06 Page 21 Cumberworth Lodge Version 5.1 8 OP28 18(1) 9 OP30OP38 18(1) 13(4) 10 OP31 10(3) 9(2)(b) 11 OP33 35 12 OP36 18(2) 13 OP38 13(4) 14 OP38 23(4) ensure that all records relating to recruitment are available for inspection. 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. (Previous timescale – 31 December 2005 - was not met) The registered person must provide evidence to the Commission that all staff have received updates in mandatory training. The registered person must ensure that the manager has achieved NVQ level 4 in management and care. (Previous timescale – 31 December 2005 - was not met) The registered person must ensure that the quality assurance systems are maintained. (Previous timescale –31 September 2005 - was not met) The registered person must ensure that staff receive regular supervision at least 6 times per year. (Previous timescale –31 September 2005 - was not met) The registered person must provide evidence to the Commission that the gas boiler, portable electrical equipment and emergency lights have been serviced. The registered person must provided evidence tot eh Commission that all staff have attended a fire drill. 01/06/06 14/04/06 01/10/06 01/06/06 01/06/06 14/04/06 14/04/06 Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP19 OP23 Good Practice Recommendations The registered person should include service users views in the service users guide. The registered person should develop a refurbishment plan and maintain records of maintenance work completed. The registered person should extend the bedroom that is under 9.3 square metres. Cumberworth Lodge DS0000002912.V282751.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle 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 DS0000002912.V282751.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!