Care Home: Cumberland Court

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What the care home does well Cumberland Court provides prospective residents with good information about the home and the services they can expect to receive when coming to live in the home. A full assessment of need is also carried out prior to a resident coming to live in the home. Assessments are also obtained from Care Managers of the funding local authority and where relevant hospital assessments are also obtained. Care plans are informative and based on the pre-admission assessments. There are good individual risk assessments in each individual care plan. All care plans are reviewed on a regular basis to reflect the changing needs of the residents. Residents` spoke highly of the home and being given choices in the daily lives as well as the standard of food, the activities provided by the home. Residents` praised the registered manager and the staff for the level of care they receive. The home has an up to date complaints policy and procedure, and residents` felt confident that any complaint they made would be dealt with appropriately. The registered manager and staff have good knowledge of infection control procedures. The home is well decorated and maintained, and found to be clean and odour free throughout. What has improved since the last inspection? All staff have received fire training. Since the last key inspection on the 15/08/06 a new decked patio area has been constructed at the rear of the building with better access via a new door, which has been constructed in the bay window of the dining room. The home has been kept in a good state of decoration and repair, and several bedrooms have had new carpets laid. What the care home could do better: There has been a period in the home where a number of care staff have resigned. This has left the home very short of care staff, and at the present time the registered manager is working a number of care staff shifts. While medication is generally well managed in the home a few improvements need to be made to ensure residents are not placed at risk. To the side of the new patio area is an expanse of concrete with steep concrete steps leading down to a cultivated garden and to one side of this steps is a trellis fence, this whole area needs to be made more secure so as not to place residents at risk of harm. While the majority of care staff working in the home had mandatory training the inspector noted that some staff need to up-date their mandatory training. Especially in the areas of moving and handling, basic first aid, medication, adult protection and infection control. The quality assurance system used in the home needs to be further developed to ensure that visiting professionals to the home have their views sort regarding the quality of care in the home. The registered manager should develop quality monitoring of systems used in the home, such as care planning, reviews, risk assessments, medication, cleaning, cooking and food preparation and the presentation of laundry done in the home. Some areas of the quality assurance system also need to be updated in regard to the Health and Safety and Fire Safety check which was carried out last year. CARE HOMES FOR OLDER PEOPLE Cumberland Court 6 Cumberland Gardens St Leonards On Sea East Sussex TN38 0QL Lead Inspector June Davies Unannounced Inspection 09:30 26 September 2008 th 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 Cumberland Court DS0000042898.V367392.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. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberland Court Address 6 Cumberland Gardens St Leonards On Sea East Sussex TN38 0QL 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) 01424 432949 Liz.Crotty@cumberlandcourt.co.uk PJP Care Ltd Mrs Julie Piercy (ENID) Elizabeth Crotty Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20) Service users must be older people aged sixty-five (65) years or over on admission 15th August 2006 Date of last inspection Brief Description of the Service: Cumberland Court is situated in a residential area of St Leonards-on-Sea in East Sussex. The premises which are of the Victorian era are situated a short walk from a pleasant park, local shops, a mainline railway station and approximately 1km from the promenade and beach of St Leonards and the English Channel. The home is situated on a quiet road. Cumberland Court benefits from a homely feel throughout and is well decorated. The home benefits from a long, well maintained, and decorative rear garden. This garden is generally inaccessible to Residents with mobility needs. The home is exploring several plans, the most recent being the construction of a level path around the side of the home linking the front entrance and back garden. The home is registered to provide services for up to 20 persons. The home has 16 single and 2 double rooms [for married couples]. A number of bedrooms [7], along with communal space, are below the National Minimum Standard. The home is except from these standards due to being a pre-existing home before their implementation in April 2002. The owners of Cumberland Court, PJP Care Ltd also own a care home in Eastbourne the provider of both homes carries out regular unannounced regulation 26 visits to both homes. Information on the range of fees charged is within the homes current statement of purpose/service user guide and ranges from £370.00 to £421.00 per week. The higher rate of fee is based on room size and facilities. Charges for extras include personal items beyond the basic toiletries and activities provided by the home. Such items include newspapers, perfumes, chiropody, and hairdressing. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place over 7 hours on the 26th September 2008. The inspector spoke with 3 residents and one member of staff as well as the registered manager. A tour of the premises and an audit of medication were also carried out. The inspector looked at documentation related to the standards inspected as well as taking into account information contained within the Annual Quality Assurance Assessment. What the service does well: What has improved since the last inspection? Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 6 All staff have received fire training. Since the last key inspection on the 15/08/06 a new decked patio area has been constructed at the rear of the building with better access via a new door, which has been constructed in the bay window of the dining room. The home has been kept in a good state of decoration and repair, and several bedrooms have had new carpets laid. What they could do better: There has been a period in the home where a number of care staff have resigned. This has left the home very short of care staff, and at the present time the registered manager is working a number of care staff shifts. While medication is generally well managed in the home a few improvements need to be made to ensure residents are not placed at risk. To the side of the new patio area is an expanse of concrete with steep concrete steps leading down to a cultivated garden and to one side of this steps is a trellis fence, this whole area needs to be made more secure so as not to place residents at risk of harm. While the majority of care staff working in the home had mandatory training the inspector noted that some staff need to up-date their mandatory training. Especially in the areas of moving and handling, basic first aid, medication, adult protection and infection control. The quality assurance system used in the home needs to be further developed to ensure that visiting professionals to the home have their views sort regarding the quality of care in the home. The registered manager should develop quality monitoring of systems used in the home, such as care planning, reviews, risk assessments, medication, cleaning, cooking and food preparation and the presentation of laundry done in the home. Some areas of the quality assurance system also need to be updated in regard to the Health and Safety and Fire Safety check which was carried out last year. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 7 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. Cumberland Court DS0000042898.V367392.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 Cumberland Court DS0000042898.V367392.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): Standards 1, 3 and 6 People using this service experience good quality outcomes in this area. The homes statement of purpose and service user guide is good. They provide prospective residents with information they need to make a decision about moving into the home. The registered manager gains as much information as possible prior to a resident moving into the home to ensure their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide was reviewed in February 2008. Both documents give prospective residents comprehensive information of what the home has to offer. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 10 The inspector viewed pre-admission assessments and found them to contain good information in regard to health, personal and social care required by the prospective resident. From this pre-admission assessment the registered manager is able to establish if the care staff team have sufficient skills and knowledge to meet the prospective residents needs and to ensure that the environment is suitable for the residents needs. The registered manager also obtains plans of care and assessments from care managers of the local authority. The home does not offer intermediate care. Cumberland Court DS0000042898.V367392.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): Standards 7, 8, 9 and 10 People using this service experience good quality outcomes in this area. Residents know that their personal goals are reflected in their individual plans and that potential risks are managed. Personal care is offered in a way to protect residents’ privacy and dignity and promote independence. The medication in the home is generally well managed promoting good health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From four care plans viewed by the inspector on this key inspection, it was found that all care plans had been generated from the initial pre-admission Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 12 assessments. Each care plan gave staff detailed information on the actions they need to take to meet the residents assessed needs. Each care plan contained comprehensive risk assessments in regard to all daily activities with special emphasis being placed on mobility and falls. All care plans are reviewed on a monthly basis and there was evidence that these reviews take place more frequently as residents needs change. There was no evidence in the care plans that residents and or their relatives/representatives sign up to their care plan, risk assessments or reviews. Each care plan contained good evidence the residents’ health needs are promoted. Each care plan contained a personal hygiene matrix and this shows the personal hygiene tasks that staff carries out for each resident on a daily basis. None of the residents’ at the time of the inspection had any pressure areas, and from a tour of the home where there is a risk of pressure areas developing, pressure-relieving equipment is provided. The registered manager stated that should staff become concerned about tissue viability of a resident they would report this immediately to the district nurse. There was evidence in the home that some residents’ require continence aids, but there was no referral to this in the care plans. One care plan viewed showed that referral had been made via the general practitioner to the mental health team, and this was followed through with written reports on psychiatric nurse visits. Three residents’ told the inspector about how much they enjoyed the exercise sessions in the home and on the day of the inspection the inspector witnessed one of these sessions taking place on the afternoon of the inspection. Each resident has their own weight chart, and the staff, weigh residents on a regular basis. There are occasions when a resident, declines to be weighed and the registered manager has reached an agreement with the resident that this may not take place as regularly monthly. Care plans showed good evidence of general practitioner visits and there was also evidence of other health care professional visits. Three residents’ said that they had access to health care professionals as and when needed. The home has up to date policies and procedures on the receipt, storage, recording, administration and return of medications. The inspector noted that there were not current policies and procedures in place for self-administration, PRN (as required) medication, or controlled drugs. From an audit carried out of the medication in the home the inspector found that this was generally well managed, with accurate records kept of administration. Some discrepancies were found in regard to over the counter medication and mid cycle medication not being recorded accurately on the Monthly Administration Record. Eye drops and liquid medication were not dated on the bottle on the day of Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 13 opening, some eye drops had the date recorded on the box, but this is unsafe practice as the box can get damaged. A recommendation is being made, that policies and procedures are produced to cover self medication, PRN (as required medication) and controlled drugs as well as ensuring that all medication including over the counter medication is recorded appropriately onto the Monthly Administration Record and that liquid and eye medications are dated on the bottle/tube on the day of opening. On the day of the inspection the inspector observed that staff respect the residents’ rights to privacy and dignity, by ensuring that doors are shut when personal hygiene tasks are taking place and speaking to the residents in a kindly and helpful manner. Cumberland Court DS0000042898.V367392.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): Standards 12, 13, 14 and 15 People using this service experience good quality outcomes in this area. Residents are offered a choice in regard to their daily lives and social activities to ensure their independence is maintained. The meals in this home are good offering both choice and variety and catering for special diets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are able to make choices in regard to their daily lives and social activities. Three residents said that they were able to have breakfast in their own bedrooms or in the dining room whatever their choice is. They said that they were able to get up in the morning and go to bed at night when they Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 15 wished to. All three residents spoke highly of the care and kindness they received in the home. Daily activities are on display on a board in the entrance to the communal lounge. Residents are offered a variety of activities to take part if they wish to. Some of the activities on offer were quizzes, sing-a-longs, bingo, board games, ball games and art and craft sessions. Residents told the inspector how much they enjoyed the activities. On the day of the inspection residents were taking part in a quiz, and this was creating a lot of laughter and debate. The home has regular visits from outside entertainers, including cuddly bunnies; pat a dogs, violinist, singers and a theatrical group. The local church and Salvation Army visit the home on a regular basis. Two residents said that they enjoy the visits from the church and Salvation Army. Another resident said, ‘that she did not like joining in church activities, but this was respected by the church visitors and the care staff in the home.’ Residents’ do have outings from time to time and the manager said that when the staff, accompany residents to hospital appointments they always ensure that residents have a cup of coffee afterwards. Recently the registered manager has escorted one of the residents to her son’s wedding. Visitors are welcome in the home at any time, and are always made welcome by the staff in the home. Residents are able to entertain their visitors in the communal lounge or in the privacy of their own bedrooms. The registered manager organises social events in the home and ensures that residents’ relatives and friends are invited. Residents have made their own arrangements as to their personal finances and have elected for families or representatives to deal with their finances for them. The menus in the home offer residents a choice of meals that are both appetising and nourishing. Three residents spoke highly of the food in the home, saying that it is always very good, and that they have no complaints. One resident does require liquidised food and the inspector observed that this is presented to the resident in an attractive and appetising manner. Through residents meetings, residents’ are able to suggest food they would like to see on the menu and this results in menus being changed on a regular basis. Where necessary staff are available to assist residents’ with feeding and they ensure that this is done in a discreet and sensitive manner. When and where necessary special diets are catered for in the home. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 People using this service experience good quality outcomes in this area. Residents know their complaints will be listened to and acted upon. Staff have good knowledge and understanding of adult protection issues, which protects the residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an up to date complaints policy and procedure, which is displayed in the home and contained within the statement of purpose. There have been no complaints to the home since the last inspection in August 2006. From talking to the residents the inspector was told that they would know how to complain, by telling either the registered manager or a member of staff. The home has up to date policies and procedures in relation to the safeguarding of vulnerable adults and whistle blowing. All staff are made aware through the course of induction about these policies and procedures. The registered manager also has a copy of the Sussex Multi Agency Policies Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 17 and Procedures for Safeguarding Vulnerable Adults. There are no adult protection issues in relation to the home at the present time. All the staff working in the home have received Safeguarding Vulnerable Adults Training. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26 People using this service experience good quality outcomes in this area. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Infection control procedures are well managed in the home due to the knowledge and experience of the registered manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cumberland Court is well presented comfortable traditionally furnished home. The inspector found that it was clean and had no odours. A new patio area that can be access by new a new door from the dining area is a recent addition to the home, and the inspector witnessed a resident sitting on this area Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 19 enjoying the view of the garden area. There are some concerns in regard to some steep concrete steps that lead from the side of the patio area down to a steep grassed garden area, and a trellis fence to one side of the patio area would not offer protection to a resident if they should lose their balance. It would be safer for residents if these steps had a gate across them and the fence was more robust and a recommendation is being made that it would be good practice to fit a gate and safer fence. The kitchen in the home is in need of refurbishment and this was noted by a recent Environmental Health Inspection visit. All bedrooms, some of which were rather small, were well furnished and maintained. All bedrooms have call bells in situ, radiators covered, and window opening restrictors fitted. Some bedrooms have en suite facilities. None of the bedrooms had an unpleasant odour and all were very clean. There was evidence that residents are able to bring many personal items into the home with them. There are three communal bathrooms in the home, one is a wet room, with chair fixed to the wall over the shower, another bathroom has a standing hoist by the side of the bath, and the third bathroom is a domestic type bathroom with no mobility or access aids. The home does not benefit from much storage space. The laundry room is situated in the basement of the home, and fitted with an industrial washing machine, and industrial tumble drier. This room needs decorative refurbishment, and the floor while impervious to water also needs some attention. The laundry room has hand-washing facilities and red alginate sacks are used for fouled laundry. All staff are supplied with disposable aprons and gloves, white for personal hygiene tasks, laundry and clearing up spillages, and blue for handling food. All communal hand-washing facilities have liquid soap and paper hand towels. Two of the staff have received infection control training, but through the manager’s knowledge and supervision other staff have the skills to manage infection control in the home. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 People using this service experience good quality outcomes in this area. Staffing levels in the home need to improve to ensure that all the personal, health and social care needs of the residents are met. Recruitment practices are good resulting in residents receiving care from appropriately vetted staff. Staff receive the required mandatory training but the manager must ensure that this is kept up to date to ensure that staff are able to update their knowledge and skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector does have concerns in that a number of care staff have left the home recently, two of these staff have left to further their careers in care. The registered manager told the inspector that she is covering a lot of shifts in the home at the present time and this is detracting from her management duties. Another member of staff said that staffing shortages is making the job hard at the present time, but the manager is doing her best to ensure that Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 21 care staff, get time off, and at the same time ensuring that shifts are covered. The registered manager stated that while she does not like using agency staff, as this does not give continuity of care for the residents, she has been using an agency member of staff at weekends. Residents said that there are always enough staff on duty to meet their needs. At the present time there are only fifteen resident in the home, and one of these is in hospital. The home also employs two part-time cleaners and a cook. A requirement is being made that staffing levels must be maintained to meet the assessed needs of the residents in the home. 50 of care staff working in the home have achieved their NVQ level 2 or above qualification. The inspector viewed two staff files and found that the registered manager had applied for Protection of Vulnerable Adults Register, Criminal Records Bureau checks and two references prior to them taking up employment in the home. Both files contained a photograph and evidence of identification. It was noted that one application form did not require a full employment history but this was on an old format, later applications for employment do request a full employment history. Both members of staff have received initial induction as well as skills for care induction. The staff, training matrix was out of date and showed names of recent leavers. From this training matrix the inspector found that all staff employed in the home had received fire training, four staff had protection of vulnerable adults training, three staff had basic first aid but one was out of date, five staff have received basic food hygiene training, four staff have moving and handling training, two staff have training in administration of medication. The registered manager said that she is in the process of booking further distance learning for medication and looking into distance learning packs for other mandatory training issues. A recommendation is being made that mandatory staff training should be kept up to date and current. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 and 38 People using this service experience good quality outcomes in this area. The registered manager has a good understanding of what needs to improve in the home. The quality assurance system in the home still needs further development to ensure that the home offers the highest standard of care to its residents. Staff receive regular supervision to ensure that residents receive a good standard of care. Residents and staff live and work in a healthy and safe environment where the level of risk is kept to the minimum. This judgement has been made using available evidence including a visit to Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 23 this service. EVIDENCE: The registered manager has many years experience at management level and has obtained her NVQ level four and Registered Managers Award. There is evidence in the training matrix that she also undertakes a variety of other training courses to ensure that her skills and knowledge are up to date. She has obtained train the trainers award. The inspector does have some concerns regarding the number of care staff shifts the registered manager is covering at the present time, as this detracts from her management role. Both residents and staff spoke highly of the manager. Residents described her as lovely, always willing to help them and spend time chatting to them. Staff said that she does her best to be fair to all, and is always available to listen or help out. The registered manager is in the process of preparing to send out resident and relative surveys for 2008. She has yet to develop a stakeholder survey, but through conversation with the inspector is now aware of who stakeholders are, and whom she needs to survey. While the manager is aware of the need to monitor systems used in the home she does not record this monitoring, from this inspection she is now aware of developing a recorded monitoring system to ensure that in all areas the home is offering a quality service for its residents. An improvement plan has been developed for year 2007 to 2008, and it was noted that some improvements mentioned in this plan have taken place, and three further improvements still to be made. The inspector was shown a health and safety and fire risk assessment for the home. A recommendation is being made that further improvements are made to the quality assurance system in the home. A recommendation is being made that the quality assurance system is developed further to include views of stakeholders, and monitoring of systems used in the home. The home does hold small amounts of residents’ personal allowances, but these are kept securely in the home, and individual records are kept of incoming monies, as well as expenditures, with receipts being kept of expenditure. All monies are kept safely and securely in the home. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 24 From staff personnel files the inspector noted that staff receive regular recorded supervision. The registered manager said that through supervision, she is able to discuss, policies and procedures, any issues that may have arisen, and if needed some training takes place. As mentioned under staffing in this report the majority of staff, employed in the home have completed most of their mandatory training in health and safety issues. The registered manager carries out regular weekly checks of the fire call bell system, but it was noted that a fire drill is due. Emergency lighting is tested on a regular basis as well as hot water temperatures. There are policies and procedures in place for Health and Safety, Control of Substances Hazardous to Health and Reporting of Injuries, Diseases and Dangerous Occurrences. All appliances used in the home have up to date maintenance certificates. All accidents to residents are reported into a Health and Safety Executive accident book by the staff. These accident forms, were seen to be appropriately completed. The level of accidents to residents’ is low, and most probably reflects the good risk assessments for individuals in care plans. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 26 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 OP27 Regulation 18 (1)(a) Requirement The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Timescale for action 01/12/08 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 OP9 Good Practice Recommendations All medication brought into the home (including over the counter and mid-cycle medication) should be entered onto the Monthly Administration Sheet with the date, quantity of medication and initialled by the person receiving the medication into the home. DS0000042898.V367392.R01.S.doc Version 5.2 Page 27 Cumberland Court 2. 3. 4. OP19 OP30 OP33 All liquid medication, eye drops and ointments, must have the date of opening written onto the bottle or tube, it is not good practice to write the date on the box as this can damaged and be disposed of. The garden steps should be gated off and the trellis fence replaced. Both these areas pose a risk to frail elderly residents. Some staff in the home should have the mandatory training brought up to date. The quality assurance system in the home must be developed further to ensure that in every way the home is offering the best quality of care to its residents. Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cumberland Court DS0000042898.V367392.R01.S.doc Version 5.2 Page 29 - 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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