Inspection on 17/10/06 for Cambrian House

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cambrian House 03/11/09

Cambrian House 08/07/08

Cambrian House 18/06/07

Cambrian House 13/03/06

Cambrian House 01/07/05

Cambrian House 17/11/04

Cambrian House 02/05/04

Cambrian House 02/04/04

Cambrian House 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cambrian House 294 Chester Road North Kidderminster Worcestershire DY10 2RR Lead Inspector Y South Unannounced Inspection 09:00 17 October 2006 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 Cambrian House DS0000018498.V306530.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. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambrian House Address 294 Chester Road North Kidderminster Worcestershire DY10 2RR 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) 01562 825537 F/P 01562 825537 None Kidderminster Care Ltd Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13/03/06 Brief Description of the Service: Cambrian House is a care home providing personal care and accommodation for up to twenty-five older people of either sex, who may have a physical disability or a mental health need associated with old age. It is located in a residential area on a main road about a mile and a half from Kidderminster town centre. The home is a large three-storey house, which has been adapted and extended for its current purpose. Accommodation for the service users is provided on the ground and first floor. On the first floor there are seven single bedrooms, five of which are en-suite and there are sixteen single bedrooms on the ground floor, thirteen of which are en-suite. There are communal bathrooms fitted with Parker baths and one conventional bathroom, and there are communal separate toilets throughout the building. Communal lounges and dining areas are also provided. Access to both floors is provided by a shaft lift and handrails are appropriately placed through the home. There is parking at the front and side of the house and at the rear there is a good-sized enclosed garden with seating and tables. The registered provider is Mr Satwinder Powar and the acting manager is Mrs Elaine Guest. Mrs Guest has submitted an application to the Commission for Social Care Inspection for registration as the manager. In the pre inspection questionnaire received by the Commission for Social care Inspection on 06/09/06 the acting manager quoted the scale of charges for the home as £1368 to £1460 each month. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social Care Inspection since 13/03/06 and the information obtained during fieldwork on 17/10/06. The fieldwork extended over seven hours during which the inspector spoke to three residents, three staff and the manager. A tour of the premises was undertaken. Prior to the fieldwork the home was asked by the Commission for Social Care Inspection to distribute questionnaires to the residents, relatives and health care professionals. These sought opinions on the quality of the service provided. No responses were received from residents, however five responses were received from relatives, one letter and one phone call, and two responses were received from health care professionals. This was a key inspection which focused on the key National Minimum Standards and the requirements and recommendation that arose out of the previous inspection. At the time of the fieldwork there were twenty residents accommodated in the home. What the service does well: What has improved since the last inspection? Following the last inspection twenty-eight areas for improvement were identified. This inspection identified that twenty-three had been addressed. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 6 A new care record system had been introduced and information was gradually being recorded to inform staff and benefit residents. The management of medication had improved and health and safety concerns had been addressed. A quality assurance system was being introduced so that areas for improvement and development in the service can be identified and addressed. 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. Cambrian House DS0000018498.V306530.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 Cambrian House DS0000018498.V306530.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are only admitted to the home if their needs can be met. Sufficient information is obtained prior to admission to enable the home to make a decision regarding a new admission. Prospective residents, and their supporters, receive the information they need to help them decide if they wish to live in the home. EVIDENCE: An intermediate care service is not provided by this home. A resident confirmed verbally that she and her relative had received the information they needed regarding the home in order to make a decision regarding admission. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 9 The manager and staff confirmed that people were welcome to visit, look round and discuss the service at any time. Copies of the Statement of Purpose, Service Users’ Guide and inspection reports, were readily available and the inspector assessed two care records that demonstrated that the home was able to meet the needs of those applicants. The records of the most recent person to be admitted demonstrated that needs were assessed before a place was offered. The new record system had been used. Although the information regarding mobilisation, foot care, falls and medication management could have been more detailed all topics had been considered. Copies of the Terms and Conditions of the home and a contract were available in one of the files assessed. The manager said that the documents for the newest resident would be drawn up following the review if they decided to make the home their permanent residence. Copies of the Terms and Conditions of Residence and Service Users’ Guides were available in each bedroom. Cambrian House DS0000018498.V306530.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available to the staff to enable them to meet most individual care needs relating to health and social care. However they would find more detail helpful. Medication is generally well managed so that residents receive prescribed medication safely. However the management of topical medicines could lead to out of date and incorrect products being used. Residents are treated with courtesy and respect and their privacy and dignity is respected. Written information is not available regarding residents’ end of life care wishes and religious needs. Specific care plans focusing on some identified needs are not available therefore there is a risk that staff will not be fully aware how to meet these needs. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 11 EVIDENCE: A new care record system had been recently introduced to the home. Much of the paper work had come from the provider’s other home, which is a nursing home. Therefore many of the forms had references to nurses and nursing practice. All these references should be deleted, as it is important that no one should be misled into believing this residential home provides nursing care over and above that provided by the Primary Health Care Team. The new care planning system contained information regarding individual needs and the plans to meet them. The care plans held no indication that they had been discussed and agreed by residents, or with their consent, their representatives. They needed to be appropriately signed. One of the five questionnaire respondents considered that communication could be improved, they believed that staff did not demonstrate a clear understanding of residents’ needs and they were not satisfied with the overall care provision. The manager said that the home was in the early stages of implementing a key worker system. It was hoped that this would address all the above concerns. Risk assessments had been undertaken in relation to pressure care, nutrition and falls, and some guidance had been provided for the staff. However these could be developed further. The statement on skin integrity was insufficient on which to base an opinion regarding the risk of skin damage developing. However a full pressure care assessment had been undertaken following admission and pressure care equipment was in use. If a risk is identified a detailed care plan needs to be generated to ensure all staff are aware of the equipment that is in use and the care that is needed. The manager said that none of the residents currently needed to use bed rails. However a very good copy of a protocol/risk assessment for use of bedrails was seen to be available for future use. The records confirmed that there were good links with the primary health care team and residents confirmed that they were able to see health care professionals when they needed to. Generally the standard of recording was good but care must be taken that all documents and entries are signed and dated by the author. There was no information available regarding residents’ end of life wishes and religious needs in the two records that were assessed. It is acknowledged that Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 12 this is a sensitive subject but if the information is not available the needs and preferences of the individual cannot be met and more distress may result. Medication was seen to be generally well managed. Records were acceptable and only trained staff administered medicines. Medication profiles were available in the two records that were assessed. However it was recommended that care plans should state who was responsible for the management of each individual’s medication (the home or the resident). Records indicated that responses to medication were monitored and responded to appropriately. The manager said that when necessary specialist advice, such as from the nurse who specialised in Parkinsons Disease, was sought. Risk assessments needed to be undertaken regarding the ability of the residents who wished to manage some or all of their medication and care plans should be drawn up when necessary describing the extent of the resident’s independence and how they will manage. When medication stock is given to the resident this must be recorded on the medication record with quantity, date and signature to aid monitoring and audit purposes. Storage was clean, tidy and secure. However the containers of eye drops, creams and ointments had not been dated when opened. This is necessary to aid audits and stock control. In addition some drugs have a very short life after their container has been opened. There were several tubes of cream in the medication fridge. None had been dated when opened, one belonged to a resident who had died and some labels were illegible. This increases the risk of errors occurring. It was observed that residents were treated with courtesy. Staff knocked on doors before entering and confirmed that they drew curtains and closed doors when necessary. All bedrooms were fitted with approved door locks that provided privacy and safety. However the broken lock on one bathroom door had been removed. Personal mail was retained where necessary for residents to open with the assistance of their relatives. Records were appropriately stored and were only available to the staff that needed to consult them. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities and stimulation is provided in which residents can choose to participate. Links are maintained with relatives and friends, and religious contacts are maintained by those who wish. Good nutritious food is provided and residents are able to choose from the menu or their own selection each day. EVIDENCE: The displayed program for social activities indicated that entertainers came to the home on a regular basis and the manager and staff said that staff also undertook in-house activities. The pre inspection questionnaire and members of staff stated that skittles, darts, colouring, basketball and singing were provided among other activities. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 14 Some residents enjoyed sitting or walking in the garden in the better weather. One questionnaire respondent stated that there was very little/no stimulation provided. It was observed during the fieldwork that several residents preferred to stay in their bedrooms. People said that they liked to stay in their room and watch the birds in the garden, watch their own television, read, knit and do word puzzles. Residents were observed sitting quietly in the lounges in the morning and during the afternoon, those who chose, participated in a sing-a-long with an entertainer. The manager said that it was very difficult to motivate some residents but their wishes regarding involvement were respected. The records that were assessed had recorded the activities that interested each individual and the sessions that they had participated in. Residents confirmed that their visitors came to see them and they could receive them in their bedrooms. The visitors’ book indicated that there was a steady stream of people to the home during the day. The manger confirmed that a local priest visited some residents every few months and one resident went out to church each Sunday. Residents confirmed that they enjoyed their food and the cook demonstrated that the required records were maintained. She confirmed that she visited all the residents each morning to ask if they wished to have the meal from the menu or any alternative. Diabetic diets were provided where necessary and every effort was made to enhance failing appetites. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters have access to the complaints procedure and the manager and staff. They are able to raise their concerns and can be confident of a response. Staff are appropriately recruited and trained to ensure the residents in the home are not at risk. EVIDENCE: A copy of the complaints procedure was displayed in the entrance to the home and in the Statement of Purpose and the Service Users’ Guide. However two of the five questionnaire respondents said that they did not know how to make a complaint. The residents who spoke to the inspector said that they had no worries, grumbles or complaints but knew who to talk to should the need arise. The relative of a previous resident had expressed concerns to the Commission for Social care Inspection (CSCI) regarding hygiene, medication and laundry. These issues had been taken up with the manager. Some concerns had been resolved and work had continued on others. The records in the home also indicated that the home had received and responded appropriately to complaints regarding the laundry, personal care and the provision of hot water. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 16 The manager confirmed that she had an open door policy and welcomed the opportunity to address anyone’s concerns. The staff who spoke to the inspector knew how to respond if concerns were drawn to their attention. Recruitment records demonstrated that applicants to the staff team had submitted application forms, undertaken interviews and checks had been made through the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults (PoVA) list. The training matrix showed that all but the most recent recruits had received PoVA training and the manager confirmed that the induction process for new staff included this in the programme. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a clean well-maintained environment that meets their needs. Appropriate action is taken to reduce the risks of cross infection. EVIDENCE: A partial tour of the home was conducted and a sample of bedrooms and communal areas were viewed. The home was clean and there was evidence of a redecoration and refurbishment programme in progress. There was a strong odour of urine in two bedrooms and the manager confirmed that it was an ongoing problem. The carpets had been changed and Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 18 were regularly cleaned. Special cleaning products had been purchased and the staff worked continuously in efforts to resolve the problem. It was observed that one bathroom was being used to store equipment when not needed for bathing. This was because of a lack of storage space for large items. The ‘sit on scales’ needed to be cleaned and the seat pad had split and needed to be replaced to address the risks of cross infection. In a bathroom upstairs the door lock had been removed as it was broken and not replaced. Building work was in progress to construct two more bedrooms with ensuites. The two rooms currently registered as doubles, were in use as singles. In due course both would be fitted with ensuites and be identified as single rooms. Because of the building work there were some displaced items of furniture around the home. The manager said that these would either be replaced, found new sites or be disposed of. It is hoped that the lack of storage facilities for large pieces of equipment has been considered in the building plans. The office consisted of two rooms that were so small meetings of only two people took place in both rooms at the same time with people in both areas talking through the connecting door open, but separated by a very thick wall. There was no exterior ventilation. The manager said that she had suggested to the provider that the working conditions would be vastly improved if the dividing wall could be removed. This sounded ideal and with the builders on site it could be a good opportunity to assess its feasibility and perhaps undertake the work. It was observed that new commercial machines had been installed in the laundry and work was about to commence repairing the wall behind so that it could be easily cleaned. Hand washing facilities, liquid soap and disposable towels were available and staff confirmed that they had ready access to personal protective equipment. Facilities were available to sort personal clothing so that they could be returned to their correct owner. The manager acknowledged that despite labelling misplaced laundry was an on going problem. This task requires concentration and care. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are appropriately recruited and trained to meet the needs of the residents. EVIDENCE: The pre inspection questionnaire indicated that five staff had left in the last seven months for different reasons. Recruitment had taken place and there were currently no staff vacancies. The pre inspection questionnaire indicated that current dependency levels were not high and the staff appeared unrushed and able to meet the residents’ needs. However one of the five questionnaire respondents considered that there were not always sufficient staff on duty. The inspector interviewed two staff. Their records indicated that they had gone through an acceptable recruitment process and had undertaken an extensive range of training courses. They were confident and understood the needs of the residents. The pre inspection questionnaire indicated that the care team numbered twelve persons of whom seven were qualified to National Vocational Qualification (NVQ) level 2 or above. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 20 The training matrix was displayed. The manager of another of the provider’s homes was taking the lead on training and expected that all staff would have undertaken mandatory training by the end of November this year. An induction programme had been purchased and was proving very good. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable management and registration has been applied for so residents and staff are able to enjoy a supportive environment. The implementation of a quality assurance system will enable the identification of areas that can be improved and developed. Some health and safety matters need to be addressed to ensure the well being of those people in the home. EVIDENCE: The acting manager has submitted an application to the Commission for Social Care Inspection for registration. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 22 Staff and resident were seen to respond well to her and described her to be ‘nice’ ‘supportive’ and ‘easy to talk to’. The staff confirmed that they had regular 1:1 sessions and detailed records were seen to be maintained. A quality assurance system had been purchased and was in the process of implementation. The home did not hold personal monies for residents. A fire risk assessment had been carried out and fire safety checks of equipment were seen. Staff received training and participated in fire drills. Records were maintained. These indicated that the training frequency needed to be increased to meet the agreement with Hereford and Worcester Fire Authority of all staff training three monthly and participation in at least one drill a year. It was observed that the building work obstructed one exterior fire door. However the manager said that the situation had been risk assessed and advice had been taken. All bedrooms in that corridor had external doors opening onto the garden and patio areas and there was a second external fire door in the corridor. It was advised that the green fire safety notices on and above the obstructed door be covered up so that confusion should not arise. The manager said that the home had gone through a period when there had been great difficulty in stabilising water temperatures at a safe level. The plumbers had finally successfully completed their work and the programme to monitor the temperature of water at the hot water outlets had recommenced. The record was seen. A risk assessment log for the home was seen. This was reviewed annually. Testing of portable electrical equipment was carried out each year and when brought into the home. This was next due to be done in November. A risk assessment was seen relating to the use of the lift. Wheelchairs were observed to be used appropriately. The manager confirmed that a COSHH file with all necessary information was available. It was observed that despite repairs the treads on the steps to the laundry had once again developed a tripping hazard. The training matrix, certificates seen and conversations held confirmed that staff were receiving training in health and safety related subjects. Cambrian House DS0000018498.V306530.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 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 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 x 2 Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Residents’ care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met. Care plans must be drawn up and signed with the resident and/or with their consent their representative. (Previous timescale of 31/01/05 and31/07/05 and 30/04/05 not met. New time scale given) The resident’s wishes regarding terminal care and arrangements after death must be discussed and recorded in order that they can be carried out. The registered person must ensure that the outcomes of risk assessments are included in the plans of care with details of appropriate interventions. Risk assessments must be undertaken regarding a resident’s ability to manage medication independently and DS0000018498.V306530.R01.S.doc Timescale for action 30/11/06 2. OP7 13 30/11/06 3 OP11 12 01/01/07 4 OP8 15 30/11/06 5 OP9 13 30/11/06 Cambrian House Version 5.2 Page 25 6 7 8 OP22 OP19 OP38 23 23 23 medication must be managed in accordance with the home’s policy and procedure, and good practice. Storage areas must be provided for aids and equipment. Equipment and the environment must be maintained in good repair. Staff must receive fire safety training in accordance with the recommendations of the Hereford and Worcester Fire Authority. 01/04/07 01/01/07 30/11/06 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 OP19 Good Practice Recommendations It is recommended that thought be given as to how the office facilities can be improved. Cambrian House DS0000018498.V306530.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cambrian House DS0000018498.V306530.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. 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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