Care Home: Cumberland Lodge

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What the care home does well People living at the home have very varied and individual needs, which staff work hard to meet within a relaxed and friendly atmosphere. People are encouraged and supported to maintain their independence. The home is pleasant for people to live in and is comfortable and well maintained.The manager and staff know people very well and are skilled at recognising people`s changing needs. There is a low staff turn over which provides consistency and stability for people. People are generally happy living at Cumberland Lodge. One said, "Since I have been unwell and moved from home to home, this home has been the best." What has improved since the last inspection? An additional bedroom and bathroom have been created in the annex area, and a bathroom refurbished in the main house to provide better facilities for people. Many people living at Cumberland Lodge had not had a formal review of their placement by the people funding their care for many years. Since the previous inspection all but two people have now had a review, to ensure that their needs continue to be met by the service. Management have worked to improve levels of staff training, so that they have the right skills to meet people`s needs. In particular staff have been trained in the management of medication and managing challenging behaviour. Recruitment is now done in a robust way with all documentation available to show that people living in the home are safeguarded by good practice. What the care home could do better: Day to day practice in managing medication should be reviewed to ensure that the highest standards are always maintained, and people know that their medications are managed safely at all times. So that people are cared for by staff that have good and developing skills, management should review the arrangements for staff induction. Staff induction should be in line with the recognised Skills for Care standards. CARE HOME ADULTS 18-65 Cumberland Lodge 22 Cumberland Avenue Southend On Sea Essex SS2 4LF Lead Inspector Ms Vicky Dutton Unannounced Inspection 29th May 2008 09:00 Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 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 Lodge DS0000015430.V365361.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 Adults 18-65. 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 Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cumberland Lodge Address 22 Cumberland Avenue Southend On Sea Essex SS2 4LF 01702 602361 01702 520659 cumberland.lodge@btinternet.com 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 David Houghton Mrs Judith Anne Hatley Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th July 2007 Brief Description of the Service: Cumberland Lodge provides 24 hour residential care and support for up to thirteen people with mental health issues. The home is a detached property, which is situated in the residential area of Southchurch. The home is close to Southend on Sea. Local amenities are close by, and there are good bus and train links to Southend and other areas. The main house has nine single bedrooms. A further four bedrooms are within a detached single story annexe to the rear of the property. The home has a well maintained garden to the rear of the property and sufficient off street parking facilities. People within the home access the local community independently or with staff support. The current fees at the home were quoted to be in the region of £750.00 per week. The provider said that fees would be negotiated on an individual basis according to people’s needs. In addition to the fees, there are additional costs to people for hairdressing, chiropody, magazines, newspapers, personal toiletries etc. A service Users Guide was available. It was stated that the Statement of purpose was in the process of being updated. People can access to a copy of the latest inspection report upon request. Cumberland Lodge DS0000015430.V365361.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 was an unannounced ‘key’ site visit. At this visit we (CSCI) considered how well the home meets the needs of the people living there, how staff and management work to provide good outcomes for people, and how people are helped to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of five and a half hours. A partial tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. The home’s Annual Quality Assurance Assessment (AQAA) was sent in to us (CSCI.) The AQAA was received on the due date and outlined how the home feel they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives involved professionals and staff. The views expressed at the site visit and in survey responses have been incorporated into this report. We were assisted at the site visit by the manager, and other members of the staff team. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: People living at the home have very varied and individual needs, which staff work hard to meet within a relaxed and friendly atmosphere. People are encouraged and supported to maintain their independence. The home is pleasant for people to live in and is comfortable and well maintained. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 6 The manager and staff know people very well and are skilled at recognising people’s changing needs. There is a low staff turn over which provides consistency and stability for people. People are generally happy living at Cumberland Lodge. One said, “Since I have been unwell and moved from home to home, this home has been the best.” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to move into the home are fully involved in the assessment process, assuring them that the home can meet their needs. EVIDENCE: One person has moved in since the previous inspection. A detailed preadmission assessment had been undertaken by the manager. This took place over several visits to their previous placement. A good level of assessment and care planning information was also available from the placing health authority. The person had been given opportunities to visit before they moved in. Six people living at the home completed surveys. All said that they were asked if they wanted to move into the home, and that they had sufficient information to decide if it was the right place for them. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have freedom of choice, and are fully supported in accordance with their wishes and identified care needs. EVIDENCE: Each person has a care file in place containing care plans and other information. Previous inspections have found care planning to be effective in ensuring people’s needs are met. Two care files were viewed as part of this site visit. These showed that care planning still provides a good basis for meeting people’s needs. Care plans reflected people’s needs and choices, and gave staff detailed information about how best to assist people. They were sensitive to people’s holistic needs. For example, recognising the need for support following a recent bereavement, and the stresses of moving into a new environment. A relative felt that what the home did well was, “Cares for and understands [relatives] real care needs.” People living at Cumberland Lodge are encouraged to be involved in planning their care and one had signed different aspects of their care documentation. Others however choose not to Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 10 be involved and just wish to live their lives without the need for frequent discussion of, and reference to their care needs. The AQAA completed by management said that the home could improve by ensuring everyone has copies of their care plans & risk assessments to encourage more involvement. Monthly reviews of people’s care take place. As far as possible this process involves the person in a one to one discussion. Since the previous inspection the manager has been successful in ensuring that all but two people living in the home have had a formal review of their care and placement by their funding authorities. People are encouraged to make choices in their daily lives and, as seen during the site visit, most follow their own routines with support and encouragement from staff as needed. Where any restrictions are necessary to support people’s assessed needs, these are kept to a minimum and are under regular review. One person said, “For five months I had no freedom as I needed a member of staff with me when I went out. I can now go out when I want.” On surveys all six people who responded said that they made decisions about what they wanted to do at all times. A relative felt that staff managed people’s identified difficulties well “with all due consideration given to their freedom of choice.” Some people have agreed to staff assisting them so that they can manage their finances more effectively. This is done in accordance with their wishes and good documentation is maintained. No one currently living at the home has an advocate involved with their ongoing support. This is an area the manager is looking into, particularly for those who have no family or other support. The AQQA said that they wished to, “Encourage service users to use advocacy services.” Comprehensive risk assessments were in place relating to relevant areas of individual need. Risk assessments had been regularly reviewed, and changes made as necessary, to ensure that they were still effective in keeping people and staff as safe as possible. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can enjoy a lifestyle that suits their individual needs and preferences. EVIDENCE: The majority of people living at Cumberland Lodge prefer to organise their own daily lives and do not take part in any formal activities. Some attend local college courses or other schemes. One person said that they enjoyed their adult education, but that it was only one day a week. A local drop in centre used to be enjoyed by a number of people, but the manager reported that the new laws relating to smoking have caused people to stop going there so much. Other formal day activities are available in the locality, which staff have previously encouraged people to attend. On surveys a visiting professional felt that more could be done to encourage outside activities. A member of staff felt that trips and outings should be considered. In the AQAA completed by management it was felt that improvements in the last twelve months were: Facilitating attendance at external activities for those Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 12 who have chosen to use them. Facilitating improved communication between service users and family. Most people make full use of the local community, shops and facilities. Visiting is open so friends and family can visit the home at any time. People are supported to maintain links with people that are important to them. Some people spend regular time at home with their family. One relative felt that staff always kept them in touch with what was happening and said, “They always contact me if there are any issues.” The manager said that everyone holds their own room key, and can come and go through the front door of the house as they wish. During the site visit people were observed to relax and spend time in their own room, either listening to music, sleeping, watching television, conversing with others living at the home and with support staff. Other people went out independently. People’s privacy and choices were respected. People are encouraged in accordance with their individual needs, and with support where necessary to undertake some household tasks. Most however choose not to participate. Staff plan basic menus on a week to week basis. People are given opportunities to contribute ideas and be part of the decision making process, relating to menu planning and shopping. People said that food at the home was good with “plenty of Choice.” People were observed to have access to the kitchen to prepare drinks and refreshments of their choice as often as necessary. A visiting professional said that the home provided “Good food and a varied menu.” Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are enabled to access good healthcare support to meet their individual needs. EVIDENCE: Observations at the site visit, and people spoken with showed that people felt confident with the way staff interact with and support them. One said, “I am very grateful to all the staff here for their kindness and hard work.” Some people living at Cumberland Lodge manage their own healthcare needs, although staff do try to monitor what is happening to ensure that people attend for hospital appointments and so on. The manager and most staff have worked with the same group of people for a number of years, and are sensitive to subtle changes in behaviours that may indicate a deterioration in people’s condition. The manager said that most people had the ongoing support of the community psychiatric team and social work support. People are supported to attend hospital and other appointments when needed. Arrangements are made for dental and eye care. A visiting professional said, “The care service Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 14 does usually seek advice and liaise closely with us in trying to improve the individuals’ health care needs. The health care needs are usually met by the care service.” Another said, “The care service has provided support and maintained the individual in the community adequately. The individual would not have otherwise been able to function independently.” A relative said, “The care home not only support my [relatives] medical condition in organising and taking them to hospital appointments etc. They also take the time to sit and talk to them and just generally make sure they are OK.” A sheet in one person’s care file that should have detailed professionals involved with their care had not been completed, so that important information was not available. The manager said that details of people’s healthcare, appointments and so on are kept within ongoing daily records. This could potentially mean that staff might miss important information if they had been off for a while. The manager said that they used to record health matters and appointments separately, but found the current system better. No one living at Cumberland Lodge currently takes responsibility for managing their own medication. Files showed that some people had signed to say that they agreed to staff assisting them with this. The system was generally well managed to keep people safe, and good information was available to staff about different health conditions and relevant medications. However some practice issues were highlighted to management. This included the need to ensure that any handwritten entries were double signed to show that the information had been checked, and the need to ensure that medication is always properly booked in so that an audit trail is maintained. Since the previous inspection eight staff have received training/refresher training in the administration of medication. The manager advised that staff do not have access to a fax machine. Regulations require that all homes have the facility to receive and send faxes to facilitate communication with GP’s, pharmacists etc. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected from abuse through clear complaints procedures and good practice. EVIDENCE: People are aware of how to raise any concerns and know who they should speak to. The manager said that each person has set 1 to 1 times when they can raise any issues, and constant informal discussions with staff provide opportunities for any concerns to be discussed. The home’s complaints procedure needs some updating to make people aware that they can also raise any concerns through the local authority or agency funding their placement. The complaints record viewed that any concerns raised had been managed appropriately. No safeguarding issues have been raised through the home or external agency. There are satisfactory policies and procedures in place to safeguard people from abuse. Guidelines from the local authorities placing at Cumberland Lodge were available. Training records and discussion with staff confirmed that staff have received training in safeguarding adults, and understood whistleblowing procedures. A safeguarding training pack is available in the home. It was said that two new staff will be attending training shortly following this site visit. Some people living at Cumberland Lodge can show behaviours that will challenge staff. Since the previous inspection, training in managing challenging behaviour has been undertaken by most staff. The manager has undertaken training in managing aggression in the workplace. Care plans and Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 16 risk assessments reflect the behavioural needs of people and offer staff advice and guidance on managing any episodes. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a pleasant and well maintained home, which meets their needs and lifestyles. EVIDENCE: Cumberland Lodge consists of the main house, and a separate annex. Both provide private and communal accommodation. Furnishings, decoration and fitments are of a good standard and the home is kept well maintained. Since the previous inspection a new bedroom and bathroom has been created in the annex, and bathrooms in the main house refurbished. There is outside garden space for people to enjoy. The manager said that there is an ongoing programme of refurbishment and maintenance. The AQAA identified planned works such as improving access to the building and the provision of a shower/wet room. It was also said that the laundry area was due to be refurbished. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 18 There is a separate laundry area, which the manager said is adequate to meet the needs of people living at the home. On the day of the site visit areas of the home seen appeared clean. On surveys people all six people said that the home was ‘always’ fresh and clean. Training records showed that staff had undertaken training in infection control. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of safely recruited, experienced and trained staff ensures that people are well supported. EVIDENCE: People spoken with were very happy with the support they received from staff. One said, “I get on well with all the staff who are nice.” A visiting professional said of staff that, “Their skills appear good, and their interactions with service users appropriate. Friendly staff provide a homely atmosphere.” On surveys people said that staff ‘always’ listened and acted on what they said, and ‘always’ treated them well. Of the home’s eleven permanent full time and two bank staff, four have completed a National Vocational Qualification (NVQ) in care at level two or above. The home have not yet reached the recommended level of having 50 of care staff trained to NVQ level two or above. Most staff at Cumberland Lodge have been in care work for a number of years and have the experience and training to meet people’s needs. The home’s training records showed that as well as receiving training in most core health and safety areas, other training relevant to the needs of people living at the Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 20 home is undertaken. This included training in diabetes and The Mental Capacity Act. The AQAA completed highlighted that it was found difficult to find and access good training in mental health issues that would increase staff’s knowledge and understanding. Management tries to get round this through gathering information from the internet and making this available to staff. Staff spoken with and responses on surveys showed that staff felt that there were good training opportunities available to them. On the day of the site visit twelve people were being accommodated. The home’s rotas showed that basic staffing levels are being maintained as three staff on each shift during the day and two awake members of staff at night. The manager’s hours are always on shift with no supernumerary hours allowed for administrative or staff management tasks. The manager said that they were happy with this arrangement and felt that they kept in touch with what was happening in the home. No cleaning or cooking staff are provided. These tasks are carried out by support workers as part of their duties. Four weeks rotas viewed showed that staffing levels are being maintained, but that some staff are still working long hours, which is not best practice. The files of two recently recruited members of staff were viewed. These showed that staff are recruited safely so that people are protected. All relevant checks such as Criminal Records Bureau checks and references had been obtained before people started work. The AQAA completed recognised that at present people living at the home are not really involved with the recruitment process, and that this is an area that management plan to improve. Staff files showed that an induction checklist is worked through, and that staff undertake a range of initial training. Staff have not yet however started a programme based on Skills for Care standards. The manager said that they had yet to gather information on this. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and well managed home. EVIDENCE: The registered manager has worked at Cumberland Lodge for nine years. They have a qualification in nursing within the mental health sector. They hope to re-start their Registered Managers Award in the near future. The manager had previously completed three units of this award, which is one recognised for people who manage care homes. There are strategies in place for people to express their views about the service, and for the quality of care to be monitored. An annual survey is carried out utilising questionnaires for people living at the home, relatives and other interested parties. Residents’ meetings do not currently take place. The manager hopes to re-introduce these to provide an open forum for people. At Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 22 the moment key workers and the manager spend 1 to 1 time with each person. Records available showed that the required monthly visits are being undertaken by the provider. However the last one available in the home was dated February 08. The manager said that others had been done, but could not locate these. The AQAA was briefly but fully completed by the manager, and received on the date it was due. The AQAA showed that management know what further improvements can be made, and plan to achieve these. The home’s AQAA showed that services and systems are checked and maintained. No health and safety issues were noted during the site visit. So that people are cared for safely regular checks of safety equipment are undertaken. Records of these were seen and also showed that periodic fire drills take place. The home consults with the fire service and have a risk assessment in place. Training records showed that staff receive a good level of training in areas relating to health and safety such as risk assessments, first aid, and fire prevention. As staff are actively involved in the preparation of food they should have training in this area. The AQAA completed indicated that only 2 of staff have received this training. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 24 NO 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 YA20 Regulation 13(2) Requirement People must be assured that their medicines are being managed in line with best practice at all times. Medication must always be properly booked in and checked by staff so that an audit trail is maintained. To ensure that health and safety is maintained, and people are cared for safely, staff that cook and manage food must receive training in food hygiene. Timescale for action 14/06/08 2. YA42 18(1) 01/08/08 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 YA20 Good Practice Recommendations To assist with the management of medicines and other aspects of managing the home, the manager/staff should have access to a fax machine. Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 25 2. YA35 So that staff always have the right skill to care for people, staff induction programmes should be based on Skills for Care Standards. Reports of visits undertaken under Regulation 26, to assess the quality of the service should be available in the home. 3. YA39 Cumberland Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Lodge DS0000015430.V365361.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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