Inspection on 02/05/07 for Caddington Hall

This inspection was carried out on 2nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Caddington Hall 10/05/06

Caddington Hall 16/02/06

Caddington Hall 08/09/05

Caddington Hall 09/03/05

Caddington Hall 04/05/04

Caddington Hall 04/09/02

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Caddington Hall Luton Road Markyate Hertfordshire AL3 8QB Lead Inspector Claire Farrier Unannounced Inspection 10:10 2nd May 2007 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 Caddington Hall DS0000019305.V332911.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. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caddington Hall Address Luton Road Markyate Hertfordshire AL3 8QB 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) 01582 840336 01582 842335 cornfool@bupa.com BUPA Care Homes (Bedfordshire) Ltd Linda Cornfoot Care Home 42 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (42) of places Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: This purpose built home is situated near the village of Markyate, just within the borders of Hertfordshire. The home occupies a secluded position off a country road with no easy access to amenities or public transport. The home was purpose built for Bedfordshire County Council in 1982, and in 1998 the care provider was transferred to Care First (a subsidiary of BUPA). All the beds, except six are contracted to Bedfordshire County Council. The home is organised in five units, of which two accommodate people with dementia. All the accommodation is on ground level and all the bedrooms are single. Only one has en-suite facilities. There are extensive grounds that are accessible to residents, including a wildlife area and sufficient car parking spaces. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective clients – this includes the current CSCI inspection report. The current charges range from £374 to £620 per week. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We talked to as many of the people who live in the home as we were able to. We also talked to some of the staff. 18 people completed Have Your Say surveys before the visit to the home, and we have used some of their comments in this report. During the inspection we spent time in the dementia units watching how the staff looked after the people who live there, and also how people spent their time. The manager sent some information about the home to CSCI before the inspection. When we were in the home we looked at the home’s records, care plans and staff files, and we made a tour of the premises. We talked to the manager about what we had seen during the day. What the service does well: All the residents who took part in the inspection are happy in the home. They said that they receive a good quality of care in the home, and the staff treat them well. One person said, “ Everything about this home has improved in the 18 months I have been here. We are very, very lucky to be here.” One Have Your Say survey included the comment, “I find the home great. I am very happy here.” The care staff that we spoke to was enthusiastic about their work, and said that they have a good level of training and support to enable them to meet the needs of the people who live in the home. The home looks after people’s medication well, and the staff that look after the medication make sure that people are given their medication properly. The staff monitors people’s health very well, but in some cases they have not had the support that they need from the health services. The people who live in the home are able to make decisions about their lives and the support that they receive. Everyone can discuss their care plan and make changes to it if they want to. There are residents’ meetings where people can discuss any concerns that they have, and make suggestions for improvements in the home. BUPA has a good system for quality assurance that includes asking the people who live in the home for their views. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 6 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. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on the needs of the people who live in the home, and access to appropriate services to enable them to meet their needs. EVIDENCE: A sample of files were inspected on each unit, and each one contained a full assessment that was completed before the resident was admitted to the home and where appropriate an assessment from Social Services. Care plans are written from the information in the assessments, and the assessments and care plans provide appropriate information so that the staff can meet each person’s needs. The assessments include risk assessments for moving and handling and the risk of falls, and other assessments are also carried out when appropriate, for example for pressure area care and for nutritional needs. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 9 The Service Users’ Guide provides information on what happens in the home for people who are thinking about moving in, and for the people who live there. It is clearly written, and produced in large print to make it easier for some people to read it. The information in the Guide includes the Statement of Purpose, which explains how the home operates, a sample contract with the terms and conditions of living in the home, and information on how to make a complaint. It also includes a copy of the last CSCI report. The staff have the experience and training to meet most of the residents’ needs. The provision of dementia care has improved over the last fifteen months. Some of the senior staff have completed a three day training course in dementia care, and most of the other care staff have had a one day training. However the observation in the dementia units showed that some staff are task orientated in their approach to people with dementia, and they lack the confidence or training to engage with the residents when they are relaxing. The activities available have improved, but there was no evidence of individual activities that are meaningful for each person (see Daily Life and Social Activities). Reminiscence boxes with meaningful pictures and other items have been fitted outside each person’s bedroom, but there is no other environmental differentiation, such as colour coding or pictorial cues to assist orientation. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is proactive in promoting a good quality of healthcare, but lack of support from the community medical services means that the staff is not able to provide the best quality of care for the frailest residents. EVIDENCE: Most people who completed “Have Your Say” surveys for the inspection, or who were spoken to on the day, said that they receive the personal care and support and the medical support that they need. One person said, “ The staff are very good.” Others commented, “To a point,” and “I am getting support, but I feel I need more.” One inspector observed the interactions between the residents and the staff in the two dementia units. The staff were respectful and treated the residents with dignity. However some staff were task orientated in their approach to people with dementia (see Choice of Home). Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 11 A sample of care plans was seen in each unit of the home. They are all clearly written, with the involvement and agreement of the person concerned. They contain appropriate information and procedures to enable the staff to provide the care that each person needs in the way that they wish. There is a monthly review of the care plan, when it is discussed and agreed with the resident, and evidence was seen that changes have been made to the care plans as a result. The residents are supported to maintain their independence. One person told the inspector, “I don’t need a lot of support, I can do everything myself.” This person’s care plan confirmed that they are self caring, and that they even manage their colostomy without assistance. The monitoring of each person’s health includes monthly assessments for the risks of falls and for pressure area care. Each person’s weight is recorded, and the staff follow procedures for any noted change in weight. These range from monitoring what the person eats and drinks, and ensuring that the food provided is fortified with extra butter and cream, to referral to the GP for medical advice. It was reported that the local GPs will only prescribe a food supplement in the case of terminal illness, and this has caused problems for the staff who would like to be more proactive in managing good nutrition for the frailer residents. The home has good support from the district nurses, but there is a lack of support when it is needed from the GPs and the community mental health team. The staff have had a lot of concern about one person who has been losing weight, and who also has some behaviour problems. The manager has asked the medical services for support since January, and eventually wrote a letter of complaint to Bedfordshire and Luton Mental Health and Social Care Partnership Trust. The letter described a lack of communication between the community mental health team and the GP, that meant that medication changes were not made as advised. The GP said there was nothing physical and on two separate occasions refused to prescribe a food supplement. It was only after sending this letter that the GP visited, on the day before this inspection, referred the person to the dietician, prescribed Ensure food supplement, and ensured the medication requested by the mental health team was prescribed. The home has good procedures for administering and recording medication, and the managers and the staff have made it a priority to ensure that they demonstrate good practice in this area that protects the people in the home from any avoidable risks. The only advice that the inspectors gave in this area was to ensure that there is a recent and clear photograph of each person on their care plans and medication record, so that there can be no risk of giving medication to the wrong person. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Wholesome and varied meals are provided within the home presenting a wellbalanced nutritious diet for the residents. Residents maintain their independence by making choices about the food and how they spend their days. There is a range of activities to suit the needs of most of the residents, but no activities take place when the activities organiser is not available. There are insufficient activities for people with dementia. EVIDENCE: There is a monthly programme of organised activities in the home. The programme that is displayed in each unit shows only six activities for the whole of May, and these include a church service and manicures as well as bingo, preparing hanging baskets, and an entertainment by a community group. A report of the activities that took place in March describes three sessions of bingo, two manicures and a church service. No other recorded activities took place during the month. Only three people who completed Have Your Say surveys for this inspection said that there are always activities arranged by the home that they can take part in. One person said, “I have no Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 13 complaints. My family are allowed to visit me whenever they want to.” But others commented that, “I can’t do as much as I would like to,” and “I would like more activities.” One person who was spoken to during the inspection said that there is a lot to do, and she enjoys the quizzes and parties. But another said that she is bored here and there is not enough to do. One person said, “You can’t expect to have things you want to do all the time, can you?” In the dementia units some of the staff spent some time talking to the residents. Some residents were observed reading a paper, and others were taken for a walk in the garden. But there was little evidence of meaningful activities and interaction for each person. There was nothing available for the people in the home to pick up and make use of by themselves. In all the units apart from one the television was on all the time, with no indication that anyone wanted it on, or that they wanted to watch the programme that was on. The activities organiser works only on Tuesdays and Thursdays, and there are not enough staff on each unit, and especially on the dementia units, to ensure that there are activities available for people to take part in at other times. Relatives and friends are welcomed into the home when they visit. Two visitors were spoken to during the inspection. They said that they are very happy with everything about the home. They are kept informed about their relative, and consulted about the care provided. The people who were spoken to during the inspection said that they are able to make decisions about their lives in the home. There are regular residents meetings, with 15 or 16 people attending these meetings. They are held as a social occasion, which encourages more people to attend. The issues that are discussed have included one person’s views on the condition of the toilets, and improvements to the units. The residents have chosen new names for the units, so that they have their own identity that is not just a number (see Environment). Information on advocacy services is available. Several people handle their own finances independently. Evidence indicates that residents are regularly consulted regarding the menu to reflect their taste and preference. The four-week menu viewed included good variety, the provision of good nutrition and choice. All service users spoken with expressed a high level of satisfaction about food. One person said that the food is good and there is lots of choice. Lunch was observed on two units, and on one dementia care unit. The tables are laid for lunch on all the units after breakfast. This meant that the dining rooms are not available for the possibility of social activities between meal times. On the dementia units this may confuse people into thinking that it is lunch time too early. However, good practice was seen, in that the residents come to the dining rooms only when the food is ready to be served. In order to encourage people to eat enough and maintain good health, especially in the dementia units, finger foods should be available for people to pick up and eat at all times throughout the day. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to safeguard the residents from abuse. Residents and relatives are confident that any complaints will be properly investigated. EVIDENCE: A satisfactory complaints procedure is in place and a leaflet is available for all residents and visitors. Almost everyone who completed Have Your Say surveys for this inspection said that they know how to make a complaint, and they were confident that they could talk to the manager or other members of staff about any concerns. No complaints have been recorded in the home since the last inspection. Comprehensive procedures for prevention of abuse are in place. Two incidents were referred to Social Services, but they did not involve any abuse. Training in safeguarding adults (protection of vulnerable adults) is available for all the staff, and the staff spoken to were aware of their responsibilities for whistle blowing. However some of the staff have not yet had training in the prevention of abuse. It is necessary for every member of staff, including the domestic staff, to have training in the prevention of abuse, in order to make sure that everyone has a full understanding of the importance of safeguarding the people who live in the home. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and gardens provide a comfortable, attractive and safe environment for the people who live there. EVIDENCE: Caddington Hall is a purpose built single storey building, set in large grounds. The decorations and furnishings are domestic in style, and provide a homely and comfortable environment. The home appeared to be generally clean, and appropriate procedures are in place for the control of hygiene and for effective management of laundry. Almost everyone who completed Have Your Say surveys for this inspection said the home is always clean and fresh. The gardens are accessible from each unit, and the grounds are inhabited by a Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 16 flock of peacocks that add character and interest. There is a courtyard garden at the centre of the home, which is arranged as a sensory garden with raised flowerbeds. The dining rooms on each unit could be used between meals to give people more opportunities for social activities (see Daily Life and Social Activities). The dementia units are no different in appearance from the other units in the home. Reminiscence boxes with meaningful pictures and other items have been fitted outside each person’s bedroom. The residents have chosen new names for the units, so that each can have its own identity. The names chosen are flower names. Signs are currently being prepared for each unit that has the name of the unit, a pictorial sign for the room, and a Braille description. The decoration of the units should also be improved to give each unit its own distinct identity. This would provide the environmental differentiation that is needed for the dementia units (See Choice of Home). Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers in the home are sufficient to ensure that all the residents’ needs are met. Good recruitment procedures and staff training make sure that, as far as possible, the residents are supported and protected in the home. EVIDENCE: All the members of staff spoken to during the inspection were enthusiastic about their work, and several said that they like the residents, and that they feel well supported. There are two care workers in each of the two dementia units during the day, and one on the other three units, with a duty senior for the whole home. At night there are three care staff, with none specifically allocated to the dementia units. The care staff work in all the units of the home, and there are no staff who work specifically on the dementia units. The staff levels are sufficient to provide personal care for the people who currently live in the home, but there are not enough staff on each unit, and especially on the dementia units, to ensure that there are activities available for people to take part in when they wish to (see Daily Life and Social Activities). The deputy manager is supernumerary on three days a week, and can help on those days Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 18 if needed, and the manager is able to ask for additional staff if there is increased need, for example due to an outbreak of illness in the home. The home has robust policies and procedures for recruitment. Two staff files were inspected for recently recruited members of staff. They both contained all the required information, including good references and a satisfactory CRB (Criminal Record Bureau) disclosure. All the staff spoken to said that they take part in regular training. The company provides a comprehensive training programme that covers all the statutory training, and other training as required for the specific needs of the service users. Three team leaders have completed a three day training course in dementia care, and most of the other care staff have had a one day training. The home has a distance-learning package on dementia care that all staff should do. It includes self assessments of what the person has learned, and the manager said that she has noticed the difference in the way care is provided by the staff who have completed the programme. The staff who work in the dementia units would benefit from some training in communication, so that they have the confidence to engage with the residents when they are relaxing, and an appropriate certified training should be considered for senior staff on the dementia units. The number of staff with NVQ qualifications has fallen from 33 to 23 since the last inspection. This may be due to experienced and qualified staff leaving the home. All the staff are encouraged to undertake NVQ qualifications, and several members of staff are very keen to start. All new staff follow an approved induction training course, and there is an expectation that they will then register for NVQ training. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The views of the residents and other involved people are actively sought in order to ensure that a good quality of care is provided. EVIDENCE: The manager has been in post at Caddington Hall for five years. She has completed the Registered Managers Award, and she has a Joseph Rowntree certificate in care and NVQ level 4 in care. She is also an NVQ Assessor in care. She has undertaken periodic training to update her skills and knowledge whilst managing the home. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 20 A sound quality assurance system is in place that meets the needs of the service. Annual questionnaires are sent to all the residents and their families, and a satisfaction survey report is produced which includes comments from the residents. BUPA carries out an annual audit of all aspects of the service provided by the home, with a resulting an action plan. The BUPA Operations Manager makes monthly visits to the home to monitor the quality of care provided. The arrangements for management of residents’ money were inspected and appeared to be accurate. Systems for managing the residents’ finances are transparent and backed up with signatures and invoices. Money is stored safely and adequate records are maintained in order to protect service users from financial abuse. Appropriate records are maintained for the health and safety of the residents and staff in the home, and staff follow the home’s policies and procedures. Visits from the fire service, the Health and Safety Executive and the Environmental Health Authority have been completed since the last inspection. All these inspections were satisfactory, and no requirements were made. One health and safety concern was noticed during this inspection. A bottle of toilet cleaner, with the flip top cap open, was left on the washbasin in one bathroom, easily accessible to the people who live in the home. It was removed immediately, but had been in the bathroom for at least five minutes before it was noticed and removed. Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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 3 X 3 2 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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. Standard OP12 Regulation 16(2)(n) Requirement The manager must make sure that everyone in the home has a choice of varied and appropriate activities throughout the day. Meaningful activities need to be developed for people with dementia, that meet each person’s individual needs. The manager must make arrangements to ensure that all staff in the home, including domestic staff, have adequate and appropriate training in the recognition and prevention of abuse. This will make sure that everyone has a full understanding of the importance of safeguarding the people who live in the home. Previous timescale of 11/08/06 not met. The manager must put measures in place to increase the number of qualified staff working in the home. This will provide a skilled and trained workforce with the competence and understanding to provide a good quality of care for the people who live in the home. DS0000019305.V332911.R01.S.doc Timescale for action 02/08/07 2. OP18 13(6) 02/08/07 3. OP28 18(1)(a) 02/11/07 Caddington Hall Version 5.2 Page 23 4. OP38 13(4)(a) All substances that may be hazardous to health must be stored securely at all times, to ensure that there is no risk to the health and safety of vulnerable residents. 02/05/07 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 OP4 Good Practice Recommendations The staff who work in the dementia unit would benefit from some training in communication, so that they have the confidence to engage with the residents when they are relaxing. In order to encourage people to eat enough and maintain good health, especially in the dementia units, finger foods should be available for people to pick up and eat at all times throughout the day. 2. OP15 Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area 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 Caddington Hall DS0000019305.V332911.R01.S.doc Version 5.2 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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