Inspection on 12/09/06 for Cambridge Nursing and Residential Care Home (The)

This inspection was carried out on 12th September 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

Cambridge Nursing and... 13/01/06

Cambridge Nursing and... 04/06/05

Cambridge Nursing and... 24/02/05

Cambridge Nursing and... 09/09/04

Cambridge Nursing and... 10/12/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Cambridge Nursing and Residential Care Home (The) 61 Cambridge Park Wanstead London E11 2PR Lead Inspector Ms Gwen Lording Key Unannounced Inspection 12th September 2006 10:30 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 Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.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 Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambridge Nursing and Residential Care Home (The) 61 Cambridge Park Wanstead London E11 2PR Address 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) 020 8989 1175 cambridgenursinghome@btconnect.com Cambridge Nursing Home Ltd Mr Abdool Rashid Mahmadkhan Ebrahimkhan Care Home 49 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (9), Old age, not falling within any other of places category (32), Physical disability (8) Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: The Cambridge Nursing and Residential Care Home is a privately owned care home with nursing for 49 people. It is registered to provide nursing and personal care and accommodation for both younger adults (18 to 65) and older people (65 plus). It is situated in Wanstead close to local shops and other amenities, and is well served by public transport. The home is a large, detached, property, set back from the main road with parking to the front, and an enclosed garden to the rear. The accommodation is spread over three floors, which are accessed by both stairs and a lift. The ground floor houses the kitchen and laundry, together with 17 bedrooms, a lounge, dining room, and conservatory. The first floor has 23 bedrooms, a lounge and a dining room, and the second floor has nine bedrooms and a lounge. There are toilets and bathrooms, with assisted baths, on each floor. Thirty-five of the bedrooms are single, with 28 having an ensuite toilet. There are also seven double bedrooms, each with an ensuite toilet. One of the joint proprietors, Mr Ebrahimkhan is also the registered manager. On the day of the inspection the fees for the home were between £450.00 and £1150.00 per week. A copy of the Statement of Purpose and Service User Guide is made available to both the resident and the family. A copy of the most recent inspection report is available on request. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 10.30am and took place over five hours. The joint proprietor/ registered manager was not on duty in the home as he was attending a conference. The senior nurse in charge and the home’s administrative staff were available throughout the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. Discussion took place with nursing and care staff; domestic, kitchen, and administrative staff. Nursing and care staff were asked about the care that residents’ receive, and were also observed carrying out their duties. The inspector spoke to a number of residents on each of the three floors, and where possible residents were asked to give their views on the service and their experience of living in the home. All parts of the home were visited and a number of staff, care and home records were looked at. The inspector would like to thank the staff and residents for their input during the inspection. What the service does well: What has improved since the last inspection? Regulation 26 visits are being undertaken regularly by the responsible individual and a copy of the report is being sent to the Commission. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 6 The registered providers have prioritised areas for staff training and this has been complemented with internal development of staff, as part of the overall ongoing training plan. More use is being of the communal areas including lounges and dining rooms and this means that residents have a variety of rooms that they can choose to relax and eat in. 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 Nursing and Residential Care Home (The) DS0000037315.V311570.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 Nursing and Residential Care Home (The) DS0000037315.V311570.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): Standards 1, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met. The home does not offer intermediate care. EVIDENCE: All records inspected have assessment information recorded and the information had been used to continue assessment following admission to the home and develop written care plans. Prospective residents and their relatives/ representatives are provided with information about the home and there is always the opportunity to visit the home prior to making any decision to move in. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 9 The Care Homes Regulations 2001 have been amended with effect from the 1st September 2006 for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the service users’ guide. Details of information to be included are contained within the amended regulations. Therefore, the service users’ guide must be reviewed and amended by the stated timescales. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.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): Standards 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet residents’ needs. There are clear medication policies and procedures for staff to follow. However, there are some inconsistencies in the recording of medication, which may result in unsafe practices. EVIDENCE: Individual care plans were available for each resident and a total of nine residents were case tracked and their care plans and related documentation inspected. The significant improvements noted at the last inspection to the standard of care planning has been maintained. All residents had comprehensive care plans, which covered health and personal care needs. There was evidence to show that care plans were being reviewed on a monthly basis and updated to reflect changing needs. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 11 The documentation/ health records relating to wound management, the management of a resident with insulin dependant diabetes; and a recently admitted resident, were examined. The records for these residents were found to be generally detailed and being adequately maintained. Risk assessments are routinely undertaken on admission for all residents around nutrition, manual handling, continence, falls and pressure sore prevention; and reviewed on a regular basis. Records are maintained of nutrition, including weight loss or gain. Whilst it was evident through discussion with staff, that appropriate action was being taken where necessary, it was sometimes difficult to elicit this information when case tracking. It is recommended that referrals to other health care professionals are more clearly recorded on the specific care plan, for example on the nutritional care plan. Records indicated that residents are seen by other health care professionals such as tissue viability nurse, diabetic nurse specialist, speech and language therapist, optician, chiropodist and dentist. Residents also attended specialist appointments where necessary, for example orthopaedic clinic and routine appointments for breast and cervical screening. In addition the home engages the services of a physiotherapist who visits the home once a week. The following issues were noted during examination of care plans and discussed with the senior nurse and nurse in charge of the respective floors: • One examination of two care plans it was noted that cot sides / lap belts were indicated for use when the residents were in bed and when being transported by wheelchair. Whilst risk assessments had been undertaken for their use, there was no record on the care plan to show that discussion had taken place with the resident’s relative/ representative or permission sought. Later these records were found to have been undertaken some time ago and archived. It is important that this information is retained on the current working care plan. One resident had been identified as having an isolated infection and whilst there was information around universal precautions, eradication protocols and good control of infection observed there was no specific control of infection care plan in evidence. This was discussed with nursing staff and a care plan was developed. There was no evidence in files of ‘End of Life’ care plans and the importance of developing these was discussed with the senior nurse. However, from discussions with staff and from viewing letters received from relatives it was apparent that staff dealt with a person’s dying and death in a sensitive manner, both for the individual and relatives. • • Turning regimes and fluid monitoring charts were generally being maintained accurately and up to date. However, there are a various separate charts for completion by staff to record food intake, fluid intake, fluid output and Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 12 elimination/ toileting chart. Whilst this information was available it is difficult to collate all this information. In addition staff are not always recording the amount of food intake only the type of food. For example, staff entries include “porridge, soup, sandwich”. The amount of food taken by the resident must be clearly recorded for example, two tablespoons; large bowl; size and number of sandwiches. This detail of recording will ensure that an accurate record is being maintained of nutrition. There are policies and procedures for the handling and recording of medicines. An audit was undertaken of the management of medicines and a random sample of Medication Administration records (MAR) charts were examined on each floor. There is one treatment room, which is located on the ground floor. The records for controlled drugs and temperature of the medicine refrigerator were in order. The following was discussed with the nurse in charge of the first floor: • Handwritten entries on MAR charts were being signed and dated by the person making the entry but the entry must also include the source of the information e.g. GP. Staff were observed to treat residents with respect and the arrangements for their personal care ensure that their right to privacy is upheld. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.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): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a general programme of activities available but more consideration needs to be given to planning activities, which are suitable to the specialist needs of people living with dementia. This will ensure that those residents who lack the capacity to be involved in the general activity programme are provided with meaningful activities suited to their specialist needs. EVIDENCE: There is a part time activity co-ordinator and the general activities programme has been reviewed and now includes regular visits by outside professional entertainers, which seem popular with many of the residents. There are small group activities run by the activity co-ordinator and she also facilitates other activities with residents who share a mutual enjoyment of cards, dominoes and other board games. On the day of the visit residents were seen to be pursuing their own interests such as playing computer games, listening to music, reading or watching television in their rooms. But it was apparent that residents on the specialist dementia unit (top floor) would not be able to do this, and generally were just sitting and not occupied in any meaningful Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 14 activities. Whilst the general programme of activities available within the home has been reviewed, there was still little evidence of any planning of activities which are suitable for those residents living with dementia nor were any specific activities for this group of residents observed during the visit. The activity co-ordinator is a full time member of care staff who is designated as the activity co-ordinator three days a week. It would appear that activities are mainly left to the remit of the activity co-ordinator and that care staff do not really participate and continue planned activities in her absence. More consideration and planning must be given to provide specialist activities for those residents living with dementia. This is an unmet requirement from the last inspection and is therefore repeated in this report with a new timescale for compliance. One resident was celebrating her birthday and the kitchen had provided a cake, small snacks and drinks. A number of residents joined her in the lounge to share her ‘birthday tea’ and staff were on hand to assist and took some photographs for her to remember the day. From discussion with staff and residents it was evident that this is arranged for all residents wishing to celebrate with fellow residents, relatives / friends. From observation and talking with several residents it was evident that the routines of daily living are flexible and varied to suit the differing needs and preferences of residents. The inspector observed members of staff allowing time for residents to express their wishes and supporting individuals to make choices in their everyday lives, for example choosing a drink and where they wished to take their meal. Relatives are encouraged to visit the home and there are no restrictions on when relatives and friends can visit. Visiting can take place in one of the lounges or in the privacy of the resident’s room. A visit was made to the kitchen and the inspector discussed the storage, preparation of food and menus with the person in charge of the kitchen at the time. Kitchen staff were aware of those residents requiring special diets and those residents with religious or cultural dietary needs. One resident is provided with Halal food and a vegetarian option is available at each meal. A good choice of meal options were available for the evening meal including soup, salads, hot dishes such as fish and vegetables, omelette and one resident had chosen tinned spaghetti, which is a personal preference. There are several Asian residents in the home and rice and an accompanying culturally appropriate dish is prepared each day. There is a daily menu and a record is maintained of what individual residents choose and eat. The lunchtime meal was observed on one of the floors. Residents received a varied, appealing and nutritious meal. Pureed meals were well presented and residents who required assistance were not hurried. Staff were observed to offer assistance where necessary and this was done discreetly and individually. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 15 Generally residents were assisted to one of the dining rooms for lunch, but others took their meal in their rooms according to their individual needs and choices. Dining tables were laid with cloths, cutlery and glasses and the settings were congenial. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out any problems or concerns and makes sure that residents and their relatives feel confident that their complaints and concerns are listened to and will be acted upon. However, the complaints record must be available at all times for inspection in compliance with Care Homes Regulations. The complaints record must also be accessible to staff at all times to ensure that complaints are recorded at the time they are made to ensure the complaints record is up to date. Staff working in the home have received training in Adult Protection/ Abuse Awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure however; the complaints record was not available during the inspection and could not be located by staff. It is a requirement that the complaints record is available for inspection at all times. At the last inspection it was evident from examining the complaints record that only formal written, or serious complaints were being logged. A requirement was made at the last inspection that all complaints made whether verbal or written must be recorded and include details of investigation, any action taken and the outcome for the complainant. The inspector was not able to evidence whether or not this requirement had been Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 17 complied with and therefore this requirement is repeated in this report with a new timescale for compliance. In discussion with several residents it was evident that they were aware of how to complain and to whom. One resident commented: “I speak to one of the staff and they sort things out”. Another resident commented: “The manager will always try to put things right if there is a problem”. There is an in house training programme for all staff in adult protection and this has been extended to include all administrative and ancillary staff and for all new staff during their induction. Those staff spoken to during the inspection were conversant with the action to be taken if they had concerns about the safety and welfare of residents. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall atmosphere in the home is welcoming with access to indoor and outdoor communal facilities and generally provides residents with pleasant surroundings in which to live. However, the refurbishment programme for the home must be progressed to ensure that all parts of the home are well maintained and provide all people living in the home with comfortable surroundings. EVIDENCE: The building was toured by the inspector, accompanied, at the start of the visit, and all areas were visited again later during the day. Some bedrooms were seen either by invitation of the resident, or with permission, whilst others were seen because the doors were open or being cleaned. There is a planned refurbishment programme for the home and this must be progressed within planned timescales and include improvements to fixtures and fittings such as Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 19 furniture. This will greatly improve the environment for all current residents and any prospective residents. The following were noted for prioritisation in the refurbishment programme: Top floor • Bathroom panel and corner of bath are cracked and require repair or replacement. • Bedrooms 1, 3 & 6 – upholstery on armchairs ripped. Requires repair or replacement. Ground floor • • • Reclining chair in the lounge being used for one resident was noted to have torn upholstery in several places and the foam padding was exposed. Requires repair or replacement. Bedroom 8 – upholstery on armchair ripped – requires repair or replacement. Large lounge – several armchairs have torn upholstery and require repair or replacement. The laundry area was visited and this was found to be clean, with soiled articles, clothing and foul linen being stored appropriately. Adaptations and equipment are in situ which are capable of meeting the needs of all residents. Call alarm systems are provided and were accessible and within reach of residents whilst in their rooms. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 20 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): Standards 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. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Staff rotas were inspected and the staffing levels and skill mix of qualified nurses and care staff, on all units of the home, was sufficient to meet the assessed nursing and personal care needs of residents. Care workers were being effectively deployed to ensure that residents choosing, or needing to remain in their bedrooms were being cared for appropriately. The home has a relatively stable staff team and effective team working was observed and evidenced throughout the inspection. Staff interacted well, both with each other and residents. A random sample of staff personnel files were inspected and these were found to be in good order with necessary references, criminal records bureau disclosures, and application forms duly completed. It was evident that the recruitment procedures are robust and in accordance with the Care Homes Regulations. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 21 . A record is maintained of staff training and records showed that staff had undertaken training in areas such as fire safety, moving and handling, adult protection and food hygiene. Staff have also recently received training in the care of individuals with dementia and diabetes; wound management and End of Life care. The pre-inspection questionnaire completed by the registered manager stated that 60 of care staff are qualified to NVQ level 2 or above. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to this service. The registered manager of the home is a well-qualified and experienced person and the resident’s benefit as the home is run in their best interests. Residents benefit from a committed staff team who have the skills and training necessary to meet their needs. EVIDENCE: The registered manager is also the joint proprietor of the home and is a qualified nurse. Policies and procedures are regularly reviewed and updated to reflect changing legislation and good practice guidance. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 23 Information taken from the pre-inspection questionnaire states that currently the registered manager does not act as an appointed agent for any resident. Resident’s financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances for several residents. Secure facilities are provided for the safe keeping of money and valuables held on residents’ behalf and written records are maintained. Regulation 26 visits are undertaken regularly by the responsible individual and a copy of the report is sent to the Commission. Whilst examining the accident/ incident reports it was noted that a small number of isolated incidents had not been notified to the Commission in accordance with Regulation 37 of the Care Homes Regulations. For example intruder in the building; assault on a member of staff by a service user. The registered person(s) must ensure that the Commission is notified of death, illness and other events occurring in the home in accordance with Regulation 37. A wide range of records were looked at including fire safety, emergency lighting, water temperature checks, accident/ incident reports, portable appliance testing (PAT) and hoist maintenance/ servicing. These records were found to be detailed, up to date and accurate. There is a Health and Safety handbook for all employees which covers safe working practices. Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 X X 3 X 3 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 3 X 3 X 3 X 2 3 Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16 Requirement The home must provide a more varied programme of activities for those residents with a specialist need such as dementia. (Timescale of 31/03/06 not met) All complaints made whether verbal or written must be recorded and include details of investigation, any action taken and the outcome for the complainant. (Timescale of 28/02/06 not met) Specific care plans must be developed for the control of infection, where appropriate. All hand written entries on Medication Administration Records (MAR) charts must include the source of the information. ‘End of Life’ care plans must be developed for all residents. The registered person(s) must ensure that the home’s record of complaints is at all times available for inspection. DS0000037315.V311570.R01.S.doc Timescale for action 31/10/06 2. OP16 22 30/09/06 3. 4. OP7 OP9 15 13 12/09/06 12/09/06 5. 6. OP11 OP16 15 17 (3) (b) 30/11/06 12/09/06 Cambridge Nursing and Residential Care Home (The) Version 5.2 Page 26 7. OP19 OP21 16 & 23 The refurbishment programme for the home must be progressed to ensure that all parts of the home are well maintained. A programme of renewal of the fabric and decoration of the 30/11/06 premises must be produced, with timescales, and a copy sent to the Commission. The registered person(s) must 12/09/06 notify the Commission of death, illness and other events occurring in the home in accordance with Regulation 37. 8. OP37 37 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cambridge Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Nursing and Residential Care Home (The) DS0000037315.V311570.R01.S.doc Version 5.2 Page 28 - 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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