Inspection on 28/11/05 for Cumbria House

This inspection was carried out on 28th November 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

Cumbria House 28/01/09

Cumbria House 24/10/07

Cumbria House 10/08/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cumbria House 84/86 Shorncliffe Road Folkestone Kent CT20 2PG Lead Inspector Mrs Penny McMullan Announced Inspection 28th November 2005 09.20 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 DS0000064465.V254497.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000064465.V254497.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cumbria House Address 84/86 Shorncliffe Road Folkestone Kent CT20 2PG 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) 01303 254019 Cumbria House Miss Julia Louise Carter Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places DS0000064465.V254497.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6 June 2005 Brief Description of the Service: Cumbria House is a detached property in Folkestone situated within easy walking distance of local amenities and public transport. The accommodation comprises of 25 single rooms and 4 double rooms. Six rooms have en suite facilities. All rooms are currently being used for single accommodation and there is a shaft lift enabling access to services users to all parts of the home. There are three communal lounges and a large dining room. The communal space per service user is 3.4 sq mts and there are ten rooms below 10 sq mts. This information must be clearly stated in the homes Statement of Purpose. There are mature, well maintained gardens which have ramps for easy access for wheelchair users. There is a large patio area where service users can sit and relax. DS0000064465.V254497.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection on 6th June 2004 Ashwood Park Healthcare Limited purchased the home on the 12 September 2005. The Registered Provider is Mr Imbrahim who has 22 years of multiple business experience and two years in healthcare. He also owns another care home in the Folkestone area. The current Registration Certificate does not reflect the correct information with regard to the Registered Provider. An amendment will be made and a new certificate issued to reflect the provider as Ashwood Park Healthcare Limited. Ms Julia Carter is now the Registered Manager of the home and has completed her Registered Manager Award. She is also a NVQ Assessor. The Inspector spoke to seven service users, four members of staff and two relatives who were visiting the home at the time of the inspection. There were 21 service users in the home at the time of the inspection and the proposed Registered Manager stated that all rooms are single occupancy and although the home is registered for 32 service users It is acknowledged that Mr Ibrahim, the Registered Provider has only been the owner of the home since 12 September and is fully aware of the extent of the refurbishment required in Cumbria House and the Registered Manager says that the resources and plans have been arranged to improve the services. The home has been in need of repair and refurbishment for some considerable time and there are issues in this report, which now require urgent attention. Reference to these issues are made throughout this report. One relative comment referred to the lack of disabled facilities in the toilet, the Registered Manager says that toilet facilities are under review and will be addressed during the refurbishment. There is also a bathroom and toilet on the first floor marked as out of order, these rooms are included in the refurbishment plan. Service users say that although repairs and refurbishment of the home is going to happen it is taking a long time. These issues have been outstanding prior to the sale of the home and Mr Ibriham the Registered provider is currently working on the plans to improve the premises and ensure that the home meets the national minimum standards. Although it is acknowledged that these issues will be addressed in the refurbishment the only progress made since the last inspection is the painting of the lounge and parts of the hallway on the ground floor. DS0000064465.V254497.R01.S.doc Version 5.0 Page 6 The Registered Manager and provider have been requested to address the following issues, which are now in urgent need of repair. The home is therefore required to inform the commission within seven days as to when the following repairs will be carried out: The windows in the lounge at the front of the building do not close properly and let the draught and rain in. There are also problems in some of the bedrooms where the windows do not close properly. One individual thermostat valve needs to be replaced in a service users room and lighting in a corridor and on the stairwell needed replacement bulbs. The bulbs were replaced during the inspection. The stair carpet on the stairs to the left of the entrance hall requires replacement. The carpet is worn away on the edges of the stairs and is a Health and Safety risk to service users, staff and visitors. Several areas in the home require new carpets, painting, redecoration and refurbishment. Only minimal progress has been made with regard to the refurbishment. A requirement has been made in this report for the Registered Provider to forward a plan of refurbishment. Service users and relative feedback indicates that the home is sometimes cold and during the inspection some radiators were working and some were not. The home is required to have the central heating system checked to ensure the home is warm at all times. What the service does well: What has improved since the last inspection? All senior staff administering medication have received training. DS0000064465.V254497.R01.S.doc Version 5.0 Page 7 A new laundry floor has been fitted. The new provider is committed to improving the environment of the home and is working on a major plan of refurbishment and redecoration. The work is scheduled to commence in January 2006. 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. DS0000064465.V254497.R01.S.doc Version 5.0 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 DS0000064465.V254497.R01.S.doc Version 5.0 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 the following standard(s): 1,6 The homes Statement of Purpose and Service User Guide are in place however the Statement of Purpose does not provide sufficient information for prospective Service Users. EVIDENCE: The new Registered Provider has amended the Statement of Purpose and the Service User Guide has been given to all service users. The Statement of Purpose lacks details as listed in Schedule 1, which outlines the information to be included in this document. The home needs to review this document and forward a copy to the Commission. A requirement has been made in this report. Standard 6 is not applicable to this home. DS0000064465.V254497.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10 The care planning/medical system of recording is not consistent to ensure staff is aware of the information they need to meet service users needs. Medication storage and the lack of safe transportation, together with lack of detail in risk assessments puts service user medication needs at risk of not being met. Personal care is offered in a way to protect Service Users privacy and dignity and promote independence. EVIDENCE: The service user plans are detailed and cover all aspects of health and social care, however the lack of accident recording and monitoring through the plans is not sufficient to ensure service users health care needs are met. The plans have been reviewed and showed evidence of service user/relative participation. Staff are not signing the daily record reports and this must be completed to ensure that the home is aware of whom is delivering personal care to the service users. DS0000064465.V254497.R01.S.doc Version 5.0 Page 11 Health care needs are monitored through the care plan and service users say they are able to see their GP in private and service users are also accompanied to out patient appointments. Moving and handling risk assessments are in place but require specific information to identify correct equipment to be used. The home uses the Nomad System for the administration of the medication. The Registered Manager has moved the medication storage but this area is not suitable and the transportation of the medication is not a safe practice. Further review is required to address these issues and a requirement has been made in this report. All senior staff administering medication has received training and the Registered Manager carries out an audit on a monthly basis. Mar sheets viewed were all dated, signed and in good order, however written information re medication needs to be countersigned to minimise the risk of recording errors. Homely remedies are checked with the GP before administration. Risk assessments for service users who self medicate are in place but require further detail to minimise the risk to service users. The Registered Manager is completing and implementing a revised medication policy and all staff will be assessed for their competency in the administration of medication. Service users stated that the staff always knock before entering the bedroom and provide their personal care with sensitivity. They said they felt supported and were treated respectfully. Staff was observed taking and encouraging service user with their daily care needs. DS0000064465.V254497.R01.S.doc Version 5.0 Page 12 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): 12,15,16 The well being co-ordinator provides assistance with activities there is a planned programme of activities for all service users to enjoy. Visitors are welcome in the home and can see their relative in the privacy of their own bedroom or in the quiet lounge. Dietary needs of Service Users are well catered for with a balanced and varied selection of food available that meets Service Users tastes and choices. EVIDENCE: The home has a well being co-ordinator who assists the service users to go shopping, to a club once a month and accompanies service users on hospital appointments. Service users confirmed that activities take place and a planned programme was displayed on the notice board. Service users confirmed visitors are welcomed and there is a large quite room or dining room available to receive visitors in private. Service users are also able to see their relatives; visitors in their bedrooms should if they choose to DS0000064465.V254497.R01.S.doc Version 5.0 Page 13 do so. There was feedback from a relative indicating that there is nowhere to visit in private. There was no evidence to uphold this comment. The current menu is on a four weekly basis, which appeared varied and nutritious. Alternatives are recorded and service users confirmed they were offered choices each day. The menu was displayed on the board in the dining room and the meal looked appetising and service users stated that the food was of a good standard. Service users can eat in the dining rooms or in the privacy of their own room. The mealtime was relaxed and unhurried with service users being able to take their time to enjoy the food. DS0000064465.V254497.R01.S.doc Version 5.0 Page 14 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): Arrangements for protecting Service Users are in place. The home has a satisfactory complaints system with some evidence that Service Users feel that their views are listened to and acted on. EVIDENCE: The complaints procedure was on display in the home and all service users spoken to say that they had no reason to complain. There have been no formal complaints since the last inspection. Service users and relatives have voiced their concerns over the lack of refurbishment of the home but no one has formally complained in writing. The proposed Registered Manager has reviewed the Adult Protection Policy including a policy and procedure with regard to physical and verbal aggression. POVA training has been arranged for senior staff and all staff will then be provided with the training. DS0000064465.V254497.R01.S.doc Version 5.0 Page 15 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): 19,25,26 There has only been minimal change in the décor or furnishings since the last inspection and lack of repair, maintenance and fitting of radiator guards puts service users, staff and relatives at risk of harm. Laundry facilities are satisfactory and policies and procedures are in place to control the risk of infection. EVIDENCE: The Registered Manager says that the plan of refurbishment will commence in January 2006 and plans have not been finalised. The new Registered Provider purchased the home in September this year and prior to this only minimal refurbishment has been carried out. There is now need to carry out urgent repairs to the windows at the front of the premises, the fitting of a thermostat valve on the radiators and to check the central heating system is working efficiently. The stair carpet is worn and torn and presents a risk to service DS0000064465.V254497.R01.S.doc Version 5.0 Page 16 users, staff and visitors. The home does not have a handyperson, which is adding additional pressure to the small jobs, which require to be done on a daily basis such as replacing light bulbs. The home has advertised for the position of handyperson but there have been no suitable candidates. A requirement has been made in this report to advise the Commission within seven days as to when these repairs will be affected. The home must also carry out the recommendations of the Environmental Health Officer with regard to the ventilation system in the kitchen. The home has carried out the action plan from the fire risk assessment. The home must continue to provide guards for the pipework and radiators throughout the home. There were concerns raised with regard to the lack of cleaning in the home at weekends. The Registered Manager has addressed this issue and care staff is currently covering minimal domestic duties at the weekend. There are two domestic assistants employed during the week and this may need to be reviewed in the future to ensure the home remains clean and tidy at weekends. The laundry room flooring has now been laid and the majority of staff has received infection control, additional training is booked for February 2006. DS0000064465.V254497.R01.S.doc Version 5.0 Page 17 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): 27,29,30 The home has an experienced staff group who demonstrated a good understanding of meeting service users needs. Recruitment polices have not been consistently followed resulting in Service Users receiving care from staff that have not been appropriately vetted. Staff are receiving mandatory training and updates in training to ensure they have the skills to meet the service users needs. EVIDENCE: There is currently a vacancy for one senior member of staff and a handyperson. The Registered Manager, Deputy Manager, Senior Carer and two carers were on duty in the morning together with two domestic a chef and kitchen assistant. The well being co-ordinator was accompanying a service user to the hospital. There is a minimum of three staff in the afternoon and two waking staff. There was feedback from relatives that sometimes there is not enough staff on duty; this could not be clarified as to when they were referring to. Relatives spoken to confirmed there is usually three staff on duty in the afternoon. The home must ensure that two written satisfactory references are in place before commencement of new employees. Terms and conditions of employment are on file and POVA first and CRB checks have been carried out. DS0000064465.V254497.R01.S.doc Version 5.0 Page 18 The home has a training matrix and all staff has or is booked to receive their mandatory training or updates. Health and Safety training is booked for 21 January 2006. There is a tick box induction specific to Cumbria House and a record of induction book, which is linked to skills for care to ensure the competency of new carers. DS0000064465.V254497.R01.S.doc Version 5.0 Page 19 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): 33,35,36,38 The systems for Service User consultation are in place. The home needs to progress action on requirements and recommendations The home has financial systems in place to support the service users, however review is required to provide safeguards for service users monies. The failure to test and record weekly fire points, the lack of safety checks and recording of accidents puts service users at risk of harm. EVIDENCE: The home has carried out a quality assurance survey and is in the process of discussing and implementing the next survey at the residents meeting scheduled for next week. The Registered Manager is in the process of amending and reviewing all polices and procedures in line with the new ownership of the home. DS0000064465.V254497.R01.S.doc Version 5.0 Page 20 Eight service users are supported with their finances and the current system needs to be reviewed to ensure that the home provides safeguard and levels of accountability with regard to services users money being paid into one account. There is a supervision programme in place and there was evidence that this is taking place however the home must ensure that supervision is provided at least six times per year. The boiler and central heating check needs to be carried out together with the electrical installation check and PAT testing. The home has experienced problems with the lift and repairs are made within the same day however the problems are continuing. The Registered Manager said that a new lift would be installed within the new refurbishment of the home. A risk assessment needs to be implemented. The recording of fire testing points was up to date until three weeks ago and the home must ensure that this is carried out on a weekly basis. There was an accident, which was recorded in the service user plan, but an accident form was not completed. The home must record all accidents/ incidents and ensure that the outcome is monitored. Environmental risk assessments are in place but further assessments are required due to the lack of maintenance of the home. A requirement has been made in this report. DS0000064465.V254497.R01.S.doc Version 5.0 Page 21 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 x 2 2 x 1 DS0000064465.V254497.R01.S.doc Version 5.0 Page 22 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 2 Standard OP1 OP7 Regulation 4, Sch1 15,13 Requirement To amend the Statement of Purpose and forward a copy to the Commission Staff are required to sign daily report sheets in care plans to identify care workers who are delivering personal care To identify specific moving and handling equipment in the risk assessments All accidents are required to be recorded and monitored through the care plan to ensure health care needs are met Review the storage and transportation of medication to provide a safe practice of work Further detail is also required in risk assessments to minimise the risk to service users in the home To countersign written entries on medicine administration sheets The home is required to provide the Commission with a detailed plan of refurbishment The following maintenance work to be arranged within one week of this report and advice given to the Commission when this work DS0000064465.V254497.R01.S.doc Timescale for action 31/12/05 30/11/05 3 OP7OP8OP 38 OP9 15,12,13 30/11/05 4 13 31/12/05 5 6 OP19 OP19 23 23 08/12/05 05/12/05 Version 5.0 Page 23 will be completed: To replace the radiator thermostat valve in room 18 To check efficiency of central heating system To effect repairs to windows in room 30, and 24, the small lounge and check all windows in front of the property and effect repairs where required To replace the carpet on the stairs to the left hand size of the entrance hall The home must ensure that two written satisfactory references are received prior to employment To provide the commission with an annual development plan To review the current financial system for service users monies To carry out safety checks for the boiler and central heating system, to carry out the check on the electrical installation and PAT testing To ensure weekly fire testing of points is recorded 7 OP29 18 31/12/05 8 9 10 OP33 OP35 OP38 12,26 20 13 31/12/05 31/12/05 31/12/05 11 OP38 13 02/12/05 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 OP25 Good Practice Recommendations To continue to ensure pipe work and radiators are guarded or have guaranteed low temperature surface DS0000064465.V254497.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 DS0000064465.V254497.R01.S.doc Version 5.0 Page 25 - 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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