Inspection on 26/05/06 for Cambridge House

This inspection was carried out on 26th May 2006.

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

Cambridge House 16/11/05

Cambridge House 16/06/05

Cambridge House 14/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Cambridge House Cambridge House 141 Gordon Avenue Camberley Surrey GU15 2NR Lead Inspector Sandra Holland Unannounced Inspection 10:00 26th May 2006 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 Cambridge House DS0000013583.V295480.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. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambridge House Address Cambridge House 141 Gordon Avenue Camberley Surrey GU15 2NR 01276 691035 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Naushad Heeroo Mrs Christine Anne Heeroo Mr Naushad Heeroo Care Home 16 Category(ies) of Dementia - over 65 years of age (11), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (16) Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the total number of persons accommodated up to 11 may be in the category (DE(E)) and 5 may be in the category (MD(E)). 16th November 2005 Date of last inspection Brief Description of the Service: Cambridge House is a care home accommodating up to 16 people aged over 65 years. Up to eleven of the people living at the home may have dementia and up to five people may have a mental disorder. The home is a large, two storey building, situated in a residential area of Camberley, a short distance from the town centre. It is well served by public transport, with the towns station within walking distance. Mr. and Mrs. Heeroo are the registered providers and Mr. Heeroo is the registered manager. As the registered manager, Mr Heeroo is in day to day control of the home and Mrs. Heeroo provides administrative support. Cambridge House DS0000013583.V295480.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 the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007. As the inspection was unannounced, n0-one at the home was aware that it was to take place. The inspection was carried out by Mrs. Sandra Holland, Lead Inspector for the service and took place over a six and a half hour period. Mr and Mrs Heeroo, Registered Providers, were present representing the service. A number of records and documents were examined, including residents’ individual plans, Medication Administration Record (MAR) sheets, staff files and the complaints and compliments record. All areas of the premises were seen and eleven residents, one visitor and six members of staff were spoken with. Further information was gathered for this inspection from the pre-inspection questionnaire which was supplied to the home. This was completed and returned to CSCI within the timescale, to allow for the information to be assessed. The people living at this home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their hospitality, time and assistance. What the service does well: Residents are provided with a high level of support and care within a homely and family style environment. The home is very clean and well presented and a programme of improvements are carried out. A stable and effective staff team are employed to meet the needs of residents. Staff treat residents in a friendly but professional manner. The providers are in day to day involvement in the home and ensure the standards of the service offered are maintained. Record keeping in the home is managed effectively and the providers are responsive to requirements. Cambridge House DS0000013583.V295480.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. Cambridge House DS0000013583.V295480.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 Cambridge House DS0000013583.V295480.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before being admitted to the home. EVIDENCE: From the records held, it was clear that the needs of residents were assessed before they were admitted to the home. The assessments of recently admitted residents were seen and these were comprehensive and included the required information. The manager stated that the needs of prospective residents are assessed at their own homes, in hospital or during a visit to the care home. For residents who are financially supported by social services, a care management assessment is carried out and a copy has been supplied to the home. The providers advised that intermediate care is not provided. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 9 Cambridge House DS0000013583.V295480.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive individual plan is held for each resident. Residents’ healthcare needs are very well met and medication appears to be administered appropriately. EVIDENCE: The manager advised that a detailed individual plan of the care and support needs of residents is drawn up, using the information gathered from the preadmission assessment. Those seen were comprehensive, contained the required information and had been reviewed monthly as required, or sooner, if indicated by changes in residents’ needs. An “end of life” plan is included within the individual plan and this notes who will make arrangements in the event of the death of a resident. It is recommended that residents’ religious preferences are included to ensure these are carried out at the appropriate time. Some religious or cultural needs Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 11 specify timescales for burial and other religious needs such as the requesting of Last Rites, may need to be recorded. Assessments of risks to residents have also been carried out and these included risks in the event of a fire, moving and handling risks, mobility risks and behavioural risks. One resident has displayed aggression to staff and although this has been included in the personal safety risk assessment, it does not give staff sufficient information regarding this type of behaviour, what may cause it and how to manage it. It is recommended that specific behavioural guidelines are drawn up to support and guide staff in the management of aggressive behaviour. Aggressive events should also be monitored and recorded as this may identify “trigger” factors which would assist in preventing them. From the records seen and speaking to residents and a visitor, it is clear that residents’ healthcare needs are very well met and that any changes in residents’ health are closely monitored and appropriate treatment is promptly obtained. Information regarding any accidents or incidents has been regularly supplied to CSCI under the requirements of Regulation 37. This regulation requires the home to notify CSCI without delay of any events which affect the well-being of residents. Notifications have been forwarded promptly and have detailed the actions taken to ensure the well-being of residents. The administration of medication in the home appeared to be well managed and the requirement regarding medication made at the last inspection had been met. It was pleasing that a recommendation made at the last inspection has been carried out. This recommended that monitoring visits are made by the pharmacist supplying the home, to assess the systems in use. Support was provided by the pharmacist to meet the requirement but no other issues were raised by the pharmacist. Staff were observed to treat residents with respect, interacting with them in a friendly manner whilst retaining a professional approach. Assistance with personal care was given discreetly and in a manner that promoted residents’ dignity and privacy. Cambridge House DS0000013583.V295480.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 24 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities are available and residents are supported to keep in touch with their families and friends. Wholesome and appetising meals are provided. EVIDENCE: The manager stated that a programme of activities is maintained and a member of staff on each shift is allocated to carry these out. Staff advised that the activity is varied according to the choice of residents and a record is kept of the activities actually carried out and which residents participated. The record was seen and included a quiz, indoor bowling, “sit to be fit”, trivial pursuit, dominoes, sing-a-longs and beauty therapy. Residents were proud to display their manicured hands and to advise that a male member of staff had attended to them. Residents spoke of maintaining contact with their families and friends, many of whom visit them at the home. A visitor advised that she was always made welcome and could see her relative anywhere in the home. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 13 Staff were seen to offer residents choices and to encourage their independence. Residents spoke of bringing their own belongings into the home to personalise their rooms and these were seen. The manager stated that most residents are supported by their representatives to manage their affairs. A four week menu was supplied with the pre-inspection questionnaire and from this it was clear that a well-balanced and nutritious diet is provided. Residents spoken to said they enjoyed their meals and portions were available to suit individual appetites. A choice of fried fish or poached fish in sauce was served as the main meal on the day of inspection, according to residents’ preferences or needs. Meals are served in the large, attractive dining room, which has tables for varying numbers of residents. Staff were seen to encourage residents to be independent and if assistance was required, this was offered in a discreet way. Cambridge House DS0000013583.V295480.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 inspected at least once during a 12 month period. 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. Any complaints are managed appropriately. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A record book is available in the main lounge, for anyone to note a complaint, comment or compliment. This was seen and a compliment was the most recent entry. Previous entries that had been made had been addressed by the manager and stated what action had been taken. The manager advised there if a resident is unable to read the complaints procedure, this is supplied to their representative on their behalf and the representative is asked to sign to show this has happened. A complaint had been made to CSCI regarding a resident who has now left the home. This was discussed with the providers and they advised of the actions taken. An offer by the providers to meet with the complainant was not taken up. From speaking to staff it was clear that they are aware of their role in the protection of residents. Staff stated that they have been made aware of what is acceptable behaviour (or not), from the beginning of their employment and this is confirmed from time to time at staff meetings. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 15 A number of staff have undertaken the Surrey Multi-Agency training in the safeguarding of vulnerable adults and an up to date copy of the policy and procedure is held in the home. Staff stated that they would report any concerns regarding abuse or potential abuse to the manager or person in charge and would not hesitate to do so. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 16 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 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 is well laid out, suited to purpose, is effectively maintained and attractively decorated. The premises are pleasant, clean and appear hygienic. EVIDENCE: All areas of the home were seen, both internally and externally and were tidy and well maintained. It was pleasing to see the home attractively decorated in a range of cheerful colours with co-ordinated furnishings. The home is spacious and light and comfortably furnished to meet the needs of service users. The garden is accessible by a ramp and was equipped for use with tables and chairs, although residents stated that they had not been able to use it recently due to poor weather. A number of containers were planted with seasonal flowers, which created a colourful viewpoint. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 17 The manager stated that a programme of annual, planned improvements and renewal is maintained and a copy was supplied at the inspection. In line with this, the carpets in a number of bedrooms had been replaced and the refurbishment of the kitchen was planned to take place two weeks after the inspection. The providers advised that they had sought advice from the local environmental health officer regarding the kitchen works and have arranged for the hot, main meal each day to be delivered by the local meals on wheels service. It was evident that the home was clean and free from odours. Hand-washing facilities with liquid soap and paper towels are provided in all appropriate places to maintain hygiene and staff were observed to use appropriate procedures to prevent the spread of infection. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A stable team of trained staff are employed to meet the needs of residents EVIDENCE: From the pre-inspection questionnaire and rota supplied, it was clear that a team of staff are employed to meet the needs of residents. The team consists predominantly of care staff, but other staff include two cooks and an administrator. Two staff also carry out a housekeeping role at allocated times. The majority of the staff have worked at the home for at least two years or more, providing a reassuring consistency for residents. The pre-inspection information states that sixty six per cent of care staff are trained to National Vocational Qualification (NVQ) Level 2 or above, which exceeds the recommended standard. A number of staff files were seen and it was clear that the recruitment of staff is carried out as required. All necessary records and documents had been obtained, including references, confirmation of identity and Criminal Record Bureau (CRB) disclosures. Where members of staff have been recruited from abroad or are working under the authorisation of a work permit, the appropriate documents have been obtained and are held on file. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 19 Staff advised that they have undertaken a number of training courses, some required by law, such as first aid, food hygiene and fire safety, and others to develop their knowledge and skills, such as National Vocational Qualifications (NVQ’s) and dementia training. Records and certificates confirming this were seen. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 20 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 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 effectively managed and a quality assurance survey has been carried out. The health, safety and welfare of residents is promoted. EVIDENCE: One of the providers is the registered manager for the home and carries out this role in a full-time capacity. The manager is qualified and experienced, with the skills and knowledge to fulfil his role. The other provider carries out the administrative role, and is currently undertaking NVQ level 4 in care to increase her knowledge and professional development. Both providers are in day-to-day involvement with the home, to ensure a high standard of care and the smooth running of the home is achieved. Two team leaders provide support and manage the home in the absence of the manager. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 21 From speaking to residents, staff and a visitor and from the records and documentation seen, it was evident that the home is effectively managed. It is very pleasing to record that no requirements are arising from this inspection. The manager stated that a questionnaire to survey the views of residents’ representatives about the quality of the service provided, was supplied in December 2005. Of the sixteen sent out, eight were returned and the feedback was positive, with a number of complimentary comments. Most replies indicated that representatives were very satisfied and felt that their relatives were well looked after. From information supplied with the pre-inspection questionnaire, the providers or manager are not involved in residents’ finances. The manager advised that practical support and transport is provided to just one resident to enable that person to manage their affairs. All other residents are either independent or are supported by their representatives to manage their affairs. The health and safety of all those in the home is well managed and of those records sampled, all were appropriately maintained. Checks, including fire alarm testing, fire system servicing and food temperature testing, have been carried out to the required frequency and were seen to be within required ranges. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 22 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 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x N/A x x 3 Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 Refer to Standard OP7 OP7 Good Practice Recommendations It is recommended that behavioural guidelines are drawn up to guide and support staff in the management of residents displaying aggression. It is recommended that residents’ religious preferences are included in the “end of life” plan to enable these to be carried out at the appropriate time. Cambridge House DS0000013583.V295480.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Cambridge House DS0000013583.V295480.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. 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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