Inspection on 05/09/07 for Cambrian Lodge

This inspection was carried out on 5th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cambrian Lodge 15/08/06

Cambrian Lodge 19/09/05

Cambrian Lodge 13/10/04

Cambrian Lodge 01/06/04

Cambrian Lodge 28/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Cambrian Lodge 4 Battery Road Portishead North Somerset BS20 7HP Lead Inspector Patricia Hellier Key Unannounced Inspection 5th September 2007 09:30 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 Lodge DS0000041626.V344406.R02.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 Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambrian Lodge Address 4 Battery Road Portishead North Somerset BS20 7HP 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) 01275 848844 01275 849649 Karen.cambrian@southwestcarehomes.co.uk South West Care Homes Mrs Karen Wendy Cox Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 28 persons aged 65 years and over requiring personal care. 15th August 2006 Date of last inspection Brief Description of the Service: Cambrian Lodge provides personal care for up to 28 people over 65 years of age. Cambrian Lodge is a pleasant period property situated in a residential area close to the lake grounds in Portishead, with gardens that are well kept. The property is owned by South West Care Homes and Mr Beale is the managing director. Cambrian Lodge has a purpose built extension and two passenger lifts offer easy access to all areas of the home. Car parking is provided at the front of the building, and there is a pleasant garden and patio to the rear. Accommodation is offered in 22 single and 3 double rooms. At present no rooms are shared and en-suite facilities are provided in 11 of these. The provider makes information available through a brochure and information pack. The information pack contains the Statement of Purpose and Service User guide and all relevant information about the home. CSCI reports are displayed in the entrance to the home and available for all to read. The fees range between £394.68 and £408.49 a week with additional charges being made for hairdressing, chiropody, newspapers, and toiletries. This information was provided in August 2007. Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 6 hours. Karen Cox, was present throughout. The Registered Manager, Mrs Before the inspection the information about the home was received from the Annual Quality Assurance Assessment (AQAA) submitted by the home and survey responses received from nine residents and one GP. The last inspection report was reviewed and all correspondence since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 10 residents, 1 relative, and 5 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Surveys had been sent to all residents and 9 were returned. All said they were very happy with the home and the care they received. Comments were “the staff are very efficient and caring”. None of the surveys sent to relatives were returned. Surveys were sent to 5 Health Care Professionals that visit the home and responses were received from 1 GP. He said was very satisfied with the overall care provided and said, “the home communicates clearly, and works in partnership”. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “I would recommend it to anyone”, “they look after me very well”. What the service does well: The home has a warm and pleasant environment with a good standard of fixtures and fittings. The staff work well as a team and ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example 5 residents spoken with said, “the home is lovely.” “The staff are kind and caring, and the food is good.” There is a good rapport between staff and residents and occupancy level are consistently high. People living at the home feel valued and cared for. Staff feel well supported and enabled to provide a high standard of care. Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 6 Meals are varied, healthy and nicely presented offering choice and variety. Residents’ health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One resident said ‘the home is excellent, I would recommend it to anyone”.’ 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. Cambrian Lodge DS0000041626.V344406.R02.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 Lodge DS0000041626.V344406.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is satisfactory and ensures that it is able to meet residents’ needs. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose, service user guide and all the information required to ensure they, or their relatives, have access to the relevant information at all times. The Statement of Purpose includes information regarding equality and diversity issues and the homes philosophy of care that includes meeting cultural and diversity needs. All residents spoken with had a copy of this. Two residents visited in their rooms were able to show the inspector their copies and said they refer to them for the meals of the day as they contain the four Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 9 week menus. A copy of the statement of purpose and service user guide is available and on display in the entrance foyer of the home. Other information leaflets on care home life and advocacy were on display in the home near to the main entrance and on the notice board outside the carer’s office. Photographs of staff members are on display near the main entrance, and other photographs of activities and outings are displayed in the lounge All residents were aware they had a contract of residency and were happy with the provision that they receive. The contracts reviewed as part of the case tracking exercise were signed and contained information about fees and the obligations of the provider and resident. The contract terms and conditions were clear and understandable. The registered manager carries out a needs based pre-admission assessment on all prospective residents. Admissions to the home take place once the registered manager is confident the residents care needs can be met. The registered provider writes to new residents, or their relatives, to confirm the home can meet their individual needs. Residents were able to recall having been visited by the manager prior to admission, and also being invited to visit the home. This enabled the prospective residents to meet other residents, see the facilities offered and look around the accommodation available. The residents’ when spoken to said ‘I am well looked after; they know what I need”. Social services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. The staff group includes persons from the European community. The registered manager is managing the cultural diversity and integration very well. Staff whose first language is not English are helped to attend English language lessons at the local college. Cambrian Lodge DS0000041626.V344406.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7,8,9,10,11 Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are well managed. Medication administration and practices are satisfactory. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include all key personal information. Three care plans were inspected and all reflected clearly current identified health and social care needs. Clear actions to met identified needs were recorded and regular evaluation noted. Only one of the three care plans showed resident’s involvement. In discussion with residents although they were not aware of their care plans they talked of their Key Worker and the discussions with them about their needs. Person centred care was evidenced through observations of practice Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 11 and discussion with staff. understood by the carers. The care plan is a working tool and clearly Staff when interviewed were clearly able to describe all the needs of the residents being case tracked and demonstrated a person centred approach to care. This is good practice but is not evidenced in care records. Health care professionals such as GP’s and district nurses visit the home as required to carry out health care checks and offer advice to staff. Evidence was seen of regular visits by the chiropodist and optician and residents being taken to other appointments as needed. Resident’s comments supported this. All care plans contained well-formulated risk assessments for Manual Handling and falls. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. One resident said, “It is just nice to have the reassurance of someone there to help”. Daily records were up to date and written in a respectful manner. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. One instance of poor practice was observed when a carer responded to a resident’s call bell by turning it off and saying they would come back. The resident said that had already been done and their need was urgent. The carer responded appropriately at that stage but told the resident they should have called sooner. The resident felt that a lack of staff contributed to the problem. (Staffing issues are discussed later in the report). The medication procedure, receipt, storage, administration and disposal were assessed. The inspector observed the administration of medicines during the visit. The medicines for daily use are stored in locked medicine trolleys that are secured to a solid wall. The staff who administer medication have received appropriate accredited training and a list of specimen signatures were recorded in the medicine administration record. Hand written prescriptions had not been signed for accountability purposes. Good practice guidelines recommend two signatures for hand transcribed entries on MAR sheets. Disposal of medicines follows the written procedure. The lunchtime medication routine observed was safe in the administration of medicines. Unsafe practice, which does not comply with the guidance, was observed when the medication trolley was left open and unattended for several minutes. The Homely Remedies policy is clear, but is not dated for review purposes, and is not signed by the local GP’s to demonstrate their agreement with it. Residents who are self medicating have been risk assessed and agreed to take responsibility for their own medication. Monthly evaluation of care plans was seen but no evidence of resident involvement with these was seen. Residents spoken with were unaware of Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 12 their care plans. Staff interviewed said they did discuss residents’ care with them but did not formally record it in the care plan. Thus the person centred approach of the home is not clearly evidenced in the care documentation. Residents who described their day-to-day routines said the staff did everything they could to assist them should they need help. Staff were observed knocking and waiting for responses prior to entering rooms and residents felt that sufficient account is made to ensure their dignity and privacy is maintained. Comments from residents included “my privacy is respected” and “staff always knock before they come in”. Since the last inspection the manager and staff have tried to encourage residents to discuss their end of life wishes so that they may be recorded on their care plan, and adhered to when the time comes. This is a sensitive issue and remains a work in progress. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. Implementation of this is seen in the integration of the overseas staff employed in the home. An example of this was also seen where an easy to use, and safe, stair guard had been fitted at the top of the stairs near the entrance for the safety of a resident who is blind. Cambrian Lodge DS0000041626.V344406.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Residents’ benefit from very flexible routines and menus. A variety of activities is offered, and residents right to choice and control over their lives is well respected, and encouraged. Friendly staff always welcome relatives and visitors. EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. Residents spoken with said, “we have plenty of choice and variety, there are quizzes and things to help keep your mind active, also outings.” “The staff are always willing to accommodate what we want”. At the end of the morning some residents were seen enjoying a movement and music session with a visiting provider. Two residents said later how much they enjoyed it. In the most recent survey of residents’ views of the home activities was seen as an area for improvement. Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 14 Since the last inspection the manager has been creative in the activities provide and all nine residents spoken with said they had improved. Two ladies particularly liked the Clothes show that visits the home, while three other were looking forward to the forthcoming outing to the zoo. All said how much they appreciated the garden and patio facilities provided for their enjoyment. Three residents said how they were enabled to maintain links with friends and the local community. Care records recorded personal preferences and routines. Staff were observed discussing meal choices with one resident. Activities were observed to have a high profile in the home and staff were keen that residents had all they needed to enjoy them. They are to be commended for their work in this homely process. Spiritual needs are catered for and the home holds a monthly church service. Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. Five residents spoke about their experiences of living at the home. Comments received indicated that residents have excellent relationships with the staff. One resident said that ‘this really is a home from home’. All the residents said that the ‘food is good’ and that they liked the daily choices offered. For example one resident said ’if you don’t like something they’ll change it’. Menus showed a varied, balanced and nutritious diet. The dining room is homely and tables well presented. The kitchen is clean, tidy and well organised. A recent Environmental Health (Food) inspection was satisfactory. Cambrian Lodge DS0000041626.V344406.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,17,18 Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. There have been no complaints since the last inspection. Residents stated that if they were not happy about anything they would speak to the manager. Residents said that the manager and staff are very approachable and they would always raise any niggles with them. Two residents, who said they had done this, were very satisfied with the outcome. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s just like home – we are one family”. A system for keeping clear records of complaints received with actions taken and outcomes are available should any complaints be received. The registered manager promotes the resident’s individual rights in the home. Information leaflets were available on how to contact advocacy agencies, and resident’s can vote at political elections if they chose, with staff enabling them to go to the polling station or obtaining a postal vote for them. Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 16 The home has a copy of the North Somerset ‘No Secrets’ Guide. A procedure for responding to allegations of abuse is available and staff were aware of it. The home has a copy of the ‘No Secrets’ in North Somerset guide and a comprehensive local policy and procedure for responding to allegations of abuse for the protection of residents. Staff interviewed were conversant with the home’s Adult Protection policy and demonstrated good knowledge of the adult protection procedure that should be followed if abuse is suspected. The home also has a Whislteblowing policy but not all staff are aware of this and understand their duty of care in relation to whistle blowing for the safety of the residents. All of the staff interviewed had an understanding of what constitutes abuse and said they had received in house training. This was verified during inspection of training records. Due to the whistelblowing issues it is recommended that staff access outside training in this area. Cambrian Lodge DS0000041626.V344406.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19,20,21,22,23,24,25,26 Residents are provided with homely, safe and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise resident independence. Satisfactory Infection Control practices are followed. EVIDENCE: The home is nicely decorated and well maintained with a welcoming atmosphere, and made comfortable with homely communal spaces. It is an adapted period building hat has been tastefully enlarged. Accommodation is provided over four floors with a shaft lift to access these. All rooms are provided with vanity units or en suite facilities. The décor, fixtures and fittings are in good order. The lounges are furnished with a variety of suitable and comfortable chairs to suit residents’ needs. The home has a well maintained Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 18 garden and patio area and conservatory for residents to enjoy. residents said how much they liked the patio area. Three The home has grab rails situated at relevant points and a shaft lift to all floors that is easily used to assist resident mobility, and aid independence within the home. All resident rooms are provided with a lockable space for securing personal possessions, if desired, and door locks if residents wish to lock their doors. Accessibility to staff could be an issue in an emergency if residents leave keys in the locks. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. The laundry floor near the washing machines is cracked and broken thus providing a potential source for cross infection. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Poor practice was observed on one occasion when a member of staff was seen walking through the home still wearing her gloves and apron used for care. The home has good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents. Cambrian Lodge DS0000041626.V344406.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are not always perceived as sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff receive regular training to ensure best practice care provision. EVIDENCE: All residents spoken with felt that there is a shortage of staff throughout the day. Two said that it has got worse in the last six months or so. During the inspection calls bells, the telephone and the doorbell were not answered immediately. One resident spoke of having to wait for staff to assist with an element of personal care that caused them distress. Another spoke of feeling staff were rushed and several times elements of care had not been completed satisfactorily, leading to discomfort and embarrassment for the resident. Five of the residents spoken with said they would like the opportunity of a bath more than once a week, but were aware that there are not enough staff for this. Residents spoken to say the staff were all very respectful but often rushed. In discussion with five members of staff all said they felt staffing levels were tight and they often felt rushed. The home has a Key Worker system in place for all residents. Residents and staff were aware of the role and said, “It Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 20 worked well”. Two residents said how much they enjoyed the contact with their key worker and the time for conversation together. Recruitment procedures are robust and all three files inspected contained the required documentation. All staff interviewed stated they had contracts of employment and job descriptions. Newly appointed staff confirmed they had completed an induction programme and evidence of this was seen. The home provides in house mandatory training with clear records of attendance and renewal dates. Evidence of specialist training accessed through outside provider was seen on the training records. Cambrian Lodge DS0000041626.V344406.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31,32,33,35,36,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Staff interviewed stated that they felt well supported by an approachable manager. Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 22 A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents and relatives. A summary report of the most recent survey was available demonstrating the responses and action taken to address identified areas of weakness. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records. It is recommended that two signatures for any transactions are made for the safeguarding of all concerned. Supervision for staff is provided both formally, and informally at hand over times and other times, when the staff discuss resident’s care needs and how best to meet them. Records seen were sporadic and did not evidence the practices spoken of by staff and the manager. Records seen showed evidence that care practices for residents and training needs were discussed. Supervision records need to show that supervision is provided at least six times a year. Information received indicated regular safety and fire checks are carried out. Information regarding certificates of safety checks, servicing of equipment and other required safety inspections was supplied. Staff spoken to confirmed that regular fire instruction and drills had taken place. Cambrian Lodge DS0000041626.V344406.R02.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 4 4 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 x 3 Cambrian Lodge DS0000041626.V344406.R02.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. Standard Regulation Requirement Timescale for action 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. 2. 3. 4. 5. 6. Refer to Standard OP7 OP9 OP18 OP26 OP27 OP36 Good Practice Recommendations To include residents in the formulation and review of their care plans. To ensure that medicines are not left unlocked and unattended To ensure all staff are aware of the whistle blowing policy and their responsibility within it. To ensure satisfactory floor surfaces are provided to prevent the potential spread of infection. To keep staffing levels under review and ensure resident needs can be fully met. To ensure documented supervision is provided six times a year for all staff Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Cambrian Lodge DS0000041626.V344406.R02.S.doc Version 5.2 Page 26 - 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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