Inspection on 10/12/07 for Cambron House Care Home

This inspection was carried out on 10th December 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

Cambron House Care Home 19/07/06

Cambron House Care Home 14/10/05

Cambron House Care Home 12/05/05

Cambron House Care Home 25/02/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOMES FOR OLDER PEOPLE Cambron House Care Home 3 Flanderwell Lane Bramley Rotherham South Yorkshire S66 3QL Lead Inspector Sue Turner Key Unannounced Inspection 10th December 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 Cambron House Care Home DS0000061782.V355719.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. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambron House Care Home Address 3 Flanderwell Lane Bramley Rotherham South Yorkshire S66 3QL 01709 543197 01709 702992 cambronhse@tiscali.co.uk 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) Kirsten Properties Limited Miss Annette Kenny Care Home 38 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (38) of places Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only - Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs are within the following categories: Mental Disorder - Code MD, and Dementia - Code DE The maximum number of service users who can be accommodated is: 38 19th July 2006 2. Date of last inspection Brief Description of the Service: The home is situated in Bramley, which is approximately 4 miles from Rotherham. Cambron House is a registered care home that provides both residential and nursing-care for people in the categories of elderly with dementia and mental disorder. The home provides both long and short-term care for its client group. Cambron House is a converted and extended building, which provides accommodation for up to 38 people in 32 single and 3 double bedrooms. The accommodation is provided over 2 floors and there is a passenger lift to the first floor. The communal space, located on the ground floor, consists of a dining room and a large lounge. The kitchen and the laundry room are also situated on the ground floor. There are garden areas at the back and in the front of the building. Car parking spaces are provided to the front and side of the home. The home is well served by regular public transport services, a range of shops, post office and a number of public houses and fast food outlets. Copies of the last Commission For Social Care Inspection (CSCI) reports were kept in the entrance for people and their families to read. The weekly fees range from: £385.00 to £581.00. This information was provided on the day of the site visit. The home charges extra for chiropody, toiletries, clothing, holidays and hairdressing. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner and Mike O’Neil, regulation inspectors. This site visit took place between the hours of 9:30 am and 3:15 pm. Julie Fletcher is the deputy manager and was present during the visit. Mel Watson the regional manager was also present for a short time. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received three questionnaires from people living in the home, three from relatives and two from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, and check the homes policies and procedures. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this ‘Short Observational Framework for Inspection (SOFI). This involved us observing up to 5 people who use services for 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. We also talked to eight staff and one relative. The inspectors checked all key standards. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 6 Comments received from questionnaires and from talking to relatives were positive and included: “Simply, thank you to all the staff at Cambron for all they do and enabling us to have peace of mind”. “I am pleased with the level of care, hygiene, food etc that is provided”. “I am happy with the choice of care home and the service provided by the management, chief nurse and all the staff”. “Dads needs are met to a high standard. The guilt I felt when I had to let dad become a resident at Cambron House has been allayed because of the excellent care he receives”. “The home meets every need that Dad has. He is safe, secure and well cared for”. Health professionals said: “People seem happy and settled at the service”. The homes statement of purpose provided sufficient information to inform people about their rights and choices. Staffing levels were sufficient to ensure that people received care and assistance when needed. Staff spoken with showed a good understanding of the need to promote peoples’ privacy and dignity and confirmed that training on dementia care is provided at the home. Staff spoke about how these qualities are promoted at the home. People said that they had a choice of food and that the quality of food served was “alright”, “eatable” and “appetising”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. Training took place, to equip staff with the essential skills needed. What has improved since the last inspection? Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 7 The homes pre admission assessment had been reviewed. It incorporated a social, recreational and religious needs form that helped staff be more aware of the persons individual needs and requirements. A full time activities coordinator had been employed. People said they enjoyed taking part in things such as games and sing-along. Trips to the butterfly house and coast had also been enjoyed. Decoration work in the home had improved the look of bedrooms and corridors. Bedrooms had been fitted with new carpets and bed linen. Different coloured doors to the toilets and dining room had made them more visible and recognisable. Staff were benefiting from formal and regular supervision. What they could do better: Up to date records should be kept, of any nursing provided to people, including a record of their condition and any treatment they are receiving. Daily entries made in care plans by the staff should be specific and relate to the actual care plan. To ensure that peoples health, safety and welfare is maintained: • • • • Where appropriate risk assessments should be completed. Medication Administration Records (MAR) sheets should be completed and signed at the time of administration. Substances that could be hazardous to health should be kept locked away. Certificates to confirm that the gas and electrical installations have been serviced as required by the health and safety and insurance policies should be available for inspection. During the SOFI observation the inspectors found that in the main when people were awake their state of well-being was positive or passive. However it was noted that one person was asleep for a period of nearly two hours and another person spent up to 1 hour asleep. Clearly during this time the people had no contact with staff or other people, which can have a negative affect on their well-being. There were no medical reasons highlighted in the peoples care plans as to why they were sleeping in the day. Staff need to make efforts to include as many people as possible in conversation and day-to-day life. Staff would benefit from additional training on how to communicate effectively with people who use the service. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 8 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. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 9 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 Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 10 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): Standards 1, 3, 4 and 5. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Pre admission information ensured the home was able to meet peoples health, social and care needs. EVIDENCE: The homes had an incorporated Statement of Purpose and Service User Guide. This was available in the entrance hall for anyone visiting the home. It included useful information about the home and the services offered. It had been updated accordingly. Professionals and staff from the home prior to admission taking place assessed people. This either took place at Cambron House or at peoples own homes if they preferred. The deputy manager said that assessments in hospitals were Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 11 also possible if needed. The managers completed a newly devised pre service assessment to assess that the home was able to meet each person’s individual needs. One relative said: “Even before Dad became a resident information was readily available about the running of the home”. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, social and personal care needs were documented in the care plans and a range of health care professionals visited the home. The current standard of care plan documentation provided little legal protection to individual staff members or the management of Cambron House. Some medication procedures and one persons health care records did not fully protect people’s health and welfare. People and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: Four plans of care were checked. These contained information on aspects of personal, social and health care needs. However the information recorded for people was not consistent. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 13 Staff said that they completed daily recordings at the end of each shift. Recordings seen, for some people, had not been completed for many days. There was little or no information about the care given to people on a daily basis. Where care plans detailed specific care requirements it was not possible to confirm if the person had received their assessed needs. The daily entries made on the care plan by staff were not specific to the actual care plan. Updated information had been recorded in care plans, however this was in different places. There was little consistency and continuity in monitoring care. This would make it very difficult for staff to remain updated with people’s current needs. The inspectors draw the staffs’ attention to the following legislation and guidance Care home regulations 2001,regulation 17 (Schedule 3, k) “Staff must keep up to date records of any nursing provided to the service user, including a record of his condition and any treatment.” Nursing Midwifery Council, Guidelines for records and record keeping “your record keeping should be able to demonstrate: a full account of your assessment and the care you have planned and provided”. The guidelines also add “the approach to record keeping that courts of law adopt tends to be that if it is not recorded, it has not been done”. At lunchtime one person was seen being assisted to eat by a member of staff. The person was laid almost horizontally in a recliner chair. The person was being given a soft diet. The inspectors asked the deputy manager about this who said that the GP had instructed staff to feed the person in an upright position. The care plan was checked and no information about this was recorded. There was no risk assessment completed about the persons needs in relation to being fed. One relative said: “We were asked things when dad first came to the home but haven’t been asked since then”. The manager said that all relatives were contacted by letter and invited to be involved in the care planning and reviewing process. A notice in the front entrance hall was on display , which also prompted relatives to become involved in reviews. A range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. Relatives said: Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 14 “We are always kept up to date with important issues, falls etc are always brought to our attention as soon as we visit”. “Staff are caring and sympathetic and very professional in the way they deal with each individual”. Medicines were securely stored around the home in locked trolleys within locked cupboards. There was evidence that managers were auditing medication administration procedures, however there were some gaps in the medication administration records (MAR), which questioned the validity of the monitoring system. Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. Staff spoken to were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer. Meals served at the home offered choice and ensured people received a healthy balanced diet. EVIDENCE: People were seen to be “getting up” at various times during the morning. The inspectors saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. One relative said: “We know we can visit at anytime, just as we would visit him if he was in his own home. We can speak to him on the telephone if we able unable to visit in person”. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 16 The home had employed a full time activities worker. People said they enjoyed being involved in such things as bingo, games and sing along. Trips outside of the home were also enjoyed. Posters in the home advertised entertainment that was planned for over the Christmas holiday. On the day of the site visit the activities worker was off duty. The inspectors saw that people received varying amounts of staff interaction and stimulation. Staff were very busy attending to ‘tasks’. Staff did attempt to involve people in a game of ‘I Spy’ but this seemed a token gesture and soon faded when staff were called to attend to other people. Staff did communicate frequently with people although over half of these interactions were recorded as neutral. This was due to staff communicating more with people either prior too or during care delivery. Some staff were uncomfortable when interacting with people. The inspectors observed one very positive interaction by a member of staff. They spoke clearly and calmly to the person, gave them time to respond and left them feeling much happier. One professional said: “Cambron House seem to have a lot of social activities to keep people entertained and to enable them to socialise”. The inspectors observed people over breakfast and lunch. Choices were available and people were asked what their meal preferences were. The tables looked very bare, with only place mats. Cutlery was brought with the meal and there were no condiments or crockery on the tables. A substantial number of people needed assistance to eat. Some people sat in the dining room and others were in the lounge. Staff were very busy and this gave a very rushed feeling to the mealtime. The inspectors noted that some people were taken into the dining room at 12 O Clock. At 12.35 they were still at the table waiting for their lunch to be served to them. During this time they weren’t offered a drink and some people became restless. The inspectors spoke the deputy manager about the dining room set up and routine. She said that the managers had recently talked about there being two sittings. The inspectors agreed that this would enhance people’s mealtime experience. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint since the last inspection. This had been investigated by the registered manager and any appropriate action taken as necessary. CSCI had not received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. Cambron House Care Home DS0000061782.V355719.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained, clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: A rolling programme of refurbishment and redecoration was underway. The AQAA stated that bedrooms had been fitted with new carpets and bed linen. Different coloured doors to the toilets and dining room had made them more visible and recognisable. The home was clean and tidy. Lounge and dining areas were domestically furnished. A tour of the building identified that some areas of the home were in need of minor repair. A handy person was employed to help maintain the Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 19 environment. Homely touches were provided, which enhanced the feeling of warmth and wellbeing. Bedrooms checked were cosy. Some people spent a lot of time in their rooms, their beds were comfortable, bed linen was clean and in a good condition. Space in the home was very limited. One room was being used as the staff room, hairdressing room and activities room. This was not ideal and was causing concern. It was difficult for the staff to take their break when others were using the room. The regional manager said that there was to be a conservatory built which would address some of the space issues. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Cambron House Care Home DS0000061782.V355719.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. Recruitment procedures promoted the protection of people and staff had completed training. EVIDENCE: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff raised concerns about staffing levels not being adequate when sickness had to be covered. They said they were willing to work extra hours to help out, but numbers were sometimes still very low. The regional manager said that there had been occasions when staffing numbers had dropped but this was not recently and the home was working above minimum levels. On the day of the site visit staffing numbers were at an acceptable level. Staff were asked about teamwork and communication and all those spoken to said they thought that this was one of their strengths and something that they did particularly well. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 21 Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. The inspectors believe that staff would benefit from undertaking training in how to talk with people that are living with dementia and have communication problems. Three care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This did not meet the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. The recruitment records of three employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Cambron House Care Home DS0000061782.V355719.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s approach benefited people and staff. The quality assurance system needed further development to ensure that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. People’s health and safety had been put at risk, in some areas. EVIDENCE: The registered manager is experienced in the care of older people and has achieved the Registered Managers Award (RMA). Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 23 Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The provider visited the home each month, spent time speaking to people and staff and then reported his findings. Other quality assurance systems had started to be put in place, but needed further development. Regular staff and relative meetings were arranged. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Fire records evidenced that fire alarm checks took place each week. Staff said that they had received fire training. The deputy manager said that a fire risk assessment had been recently carried out and they were awaiting the report from this being sent to them. During the site visit, a trolley that contained substances that could be hazardous was seen left unattended. The deputy manager was asked to move the trolley to a safe place. On the day of the site visit the managers were unable to produce any certificates to confirm that the gas and electrical installations had been serviced, although certificates were seen regarding the electrical PAT (portable appliance testing) checks. Cambron House Care Home DS0000061782.V355719.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 X X 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 3 X 2 Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP7 Regulation 15,17 (Schedule 3, k) 15 Requirement Staff must keep up to date records of any nursing provided to people, including a record of his condition and any treatment. Daily entries made in care plans by the staff must be specific and relate to the actual care plan. To ensure that peoples health, safety and welfare is maintained, risk assessments must be completed where appropriate. Timescale for action 10/12/07 2. OP7 10/12/07 3. OP7 14 10/12/07 4. OP9 13 To ensure peoples health and 10/12/07 welfare, MAR sheets must be fully completed and signed at the time of medication administration. Substances that could be hazardous to health must be kept locked away at all times. Certificates to confirm that the gas and electrical installations have been serviced as required by the health and safety and insurance policies must be provided. DS0000061782.V355719.R01.S.doc 5. 6. OP38 OP38 13 23 10/12/07 10/01/08 Cambron House Care Home Version 5.2 Page 26 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. Refer to Standard OP15 OP15 OP30 OP28 OP33 Good Practice Recommendations People would be assisted and supported better at mealtimes if there were two sittings. Mealtimes should be an unhurried and pleasant experience. Staff would benefit from additional training on how to communicate effectively with people who use the service. A minimum ratio of 50 of carers should have completed NVQ Level 2 or equivalent. A quality assurance system should be further developed to ensure that the views of people, relatives and professionals are sought, and that results of these consultations are published. Cambron House Care Home DS0000061782.V355719.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Cambron House Care Home DS0000061782.V355719.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!