Inspection on 28/06/07 for Cavendish Residential Care Home Limited

This inspection was carried out on 28th June 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

Cavendish Residential Care Home... 03/07/06

Cavendish Residential Care Home... 14/03/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Cavendish Residential Care Home Limited Cavendish Residential Care Home 26 Kings Road Clacton on Sea Essex CO15 1AZ Lead Inspector Diane Roberts Unannounced Inspection 28th June 2007 09:00 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 Cavendish Residential Care Home Limited DS0000062449.V344619.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. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish Residential Care Home Limited Address Cavendish Residential Care Home 26 Kings Road Clacton on Sea Essex CO15 1AZ 01255 423861 01255 423114 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) Cavendish Residential Care Homes Limited Manager post vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 21 persons) Three persons, over the age of 65 years, who require care by reason of dementia, whose names were made known to the Commission in October 2006 The total number of service users accommodated in the home must not exceed 21 persons 7th December 2006 Date of last inspection Brief Description of the Service: Cavendish is a care home, providing personal care and accommodation for 21 older people. Mr and Mrs Hunt, who have owned the home since 2000 and have recently registered as a Limited Company, manage the service. The home is located on the outskirts of Clacton town centre and has easy access to the local shops and other amenities. The home consists of a two storey, detached house. The bedrooms are made up of nineteen single and one double room. All but three of the rooms have ensuite facilities. There is a passenger lift. The home has private gardens, which are well maintained and accessible via a ramp. The current scale of charges is £374.00 - £450.00. Additional costs for items such as hairdressing, chiropody are charged separately. The home has an up to date statement of purpose and service users available. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The proprietor and manager were available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 3 residents, 3 relatives and 2 staff were spoken to during the inspection. Although feedback sheets were sent to residents and relatives for comment, none were returned to the CSCI. A random inspection was undertaken on the 7.12.2006, as previously the home had a history of poor compliance and an adult protection complaint. This inspection was to follow up on the last agenda for action and to check progression in the home. This report is not published, but is available upon application to the CSCI. At the time of the visit in December 2006, significant progress had been made by the management at the home to address the shortfalls and it was considered, at that time, that the CSCI need not take any legal action against the home. This inspection shows that the improvements have continued and outcomes for residents have improved significantly. What the service does well: What has improved since the last inspection? Significant improvements have been made since the last key inspection to general care provision, healthcare for residents, record keeping, the staff team and staff training, quality assurance, approach to complaints and adult protection. These have all helped to improve outcomes for residents. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cavendish Residential Care Home Limited DS0000062449.V344619.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 Cavendish Residential Care Home Limited DS0000062449.V344619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst admissions to the home are appropriate and information is available, the assessment process needs to be developed further in order to ensure that outcomes for residents are positive and all their needs are met. EVIDENCE: The team at the home have a set pre-admission assessment form in place that meets the required standard. The manager primarily undertakes the assessments, but has been training other staff in the home so that they can undertake them in her absence. A range of assessments, completed by staff from the home, were reviewed. These were supported by information contained in social services assessments that the home had been given. Admissions to the home were seen to be appropriate but some areas of the assessment did not contain enough detail, even from residents who would have been able to take an active part in the process. Where areas of need Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 9 were identified, these should be explored and more detail recorded, including the individuals’ comments or preferences, giving a more person centred approach. The team have a good care plan assessment tool in place, which may be of value to use in the pre-admission assessment. This was discussed with the manager. The Service Users Guide was seen around the home and residents had copies in their rooms. When reviewing this document, the management may wish to give further consideration to the format in relation to the needs of the residents currently in the home. This was discussed with the manager. Cavendish Residential Care Home Limited DS0000062449.V344619.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. 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. Care provision at the home is good overall, giving residents’ positive outcomes. The further development of a more person centred approach to care planning would benefit aspects of residents care even further. EVIDENCE: A new care planning system has been introduced since the last inspection. The manager has done this so care staff can take a more active part in care planning and this is evident in the records. Records show that the manager has been providing care-planning training to staff in order to facilitate this change and more is planned for the future. The care planning system has an assessment tool in place that covers activities of daily living and then links into the care planning system. This is a good tool and was seen to be completed well and gave a good level of detail about the individual. These records also identified personal preferences well. Care plans were in place for identified needs and these were seen to be generally up to date and contained a good Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 11 level of detail. It was noted that staff may need to take on board that reviews may be necessary at other than planned times, as daily notes evidenced that a sleep care plan and associated falls risk assessments should have been reviewed. This was discussed with the manager. Review notes seen were clear and reflected a good evaluation of current needs and choices. Some care plans, but not all, showed either resident or relative involvement. Relatives spoken to say that communication from the home was generally good. The manager states in her annual quality assurance assessment that the team need to involve residents, relatives and advocates in the care planning process on a more regular basis. A more person centred approach may need to be developed as the home is gradually moving towards the admission of more residents with diagnosed dementia and the staff training also reflect this. Use of more appropriate assessments and the identification of strengths and abilities would be of value in optimising residents and promoting self worth. Care plans that relate to psych/social needs and behaviour need developing further and the home should try to ensure that social histories are in place for every resident. Daily notes are recorded in the care plans. These were seen to be variable and staff should try and reflect the resident and their mood etc. rather than just the care provided. The manager states in her annual quality assurance assessment that she plans to undertake more auditing on the care planning and care provision in the next 12 months. A wide range of risk assessments are in use, for example, manual handling, falls, pressure sores, general and nutritional. These were seen to contain good detailed information and were up to date. The team need to work on linking any identified risks into the care planning system so that any action to be taken is clear and subsequently evaluated. This was particularly noted in relation to nutritional risks. Where required, records showed that a more detailed monitoring of residents falls was being undertaken in liaison with the falls prevention team. Records show a proactive input with regard to GP services. Good records are maintained of visits and advice given. Records also show that residents have regular access to chiropodists, opticians, dentists and are able to attend appointments at the hospital as outpatients. Records showed that residents’ weights are being regularly monitored. At the current time no residents in the home have a pressure sore. Some residents have pressure-relieving devices in place. The district nursing team are visiting the home to see two residents for minor healthcare issues. The home has an appropriate amount of lifting equipment for the needs of the current residents in the home. The team at the home uses a monitored dosage system and bottle to mouth. The system was inspected and found to be well managed with medication fully checked in, clear records in place and returns system in place. Staff spoken to stated that attending doctors are good at undertaking reviews and this was Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 12 evident on the MAR sheets and in the care planning records. No controlled medications were being held at the time of the inspection. Records show that senior care staff have been undertaken a distance learning course in the safe handling of medication since March 2007. The proprietor and manager undertake regular audits of the medication systems to ensure that the management is correct. Evidence in the care records show that staff appreciate the diversity of the residents that they care for. Further development of social histories and social/person centred care planning will aid this further. Residents spoken to spoke highly of the staff team and the sensitive and respectful way they delivered care. Residents spoken to also felt that their need for privacy was respected. There have been some issues with the laundry system and residents’ getting the wrong clothes back, but work has been done to improve this and relatives spoken to say this has improved recently. Cavendish Residential Care Home Limited DS0000062449.V344619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many improvements have been made and the routines of the day, the meal service and activities are resident led. Whilst residents are generally happy, individual needs could be better met if a team approach was taken. EVIDENCE: Residents daily routines are reflected to some degree in their individual care records. Records should be developed to evidence that residents have been consulted about this aspect of their lives. Sleep care plans were good and detailed residents’ choices. Residents spoken felt that they were able to spend their time as they wished and were not rushed by staff. They felt that staff were flexible and listened to their wishes. Since the last inspection the management have employed an activities officer, who is very popular with residents spoken to at the home. Individual social profiles have been completed and residents’ interests recorded, where possible the activities officer has involved the resident. Daily notes show that whilst residents are taking part in activities, these are not always relating to their noted preferences and the team as a whole could work on this aspect of care. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 14 It is clear that the activities officer is trying to meet individual requests but a team approach may help this further. Residents spoken to were very happy with the range of activities offered and events are publicised in advance. One resident said ‘the activities lady is good and all different things which I enjoy taking part, in including discussions’. On discussion, staff spoken to were very aware of residents interests and knew them well. Some residents enjoy helping out with household tasks in the home and residents spoken to confirmed this. Photos around the home evidence that social events are held and families and friends are invited and many of the staff choose to attend. The home have recently made positive links with another home and have held a tea dance where residents have been able to meet up. There are plans for residents to visit the other home. Visitors on the day of the tea dance recorded comments, for example, ‘Lovely welcome, friendly staff, altogether a lovely afternoon enjoyed by all’ , ‘I thoroughly enjoyed the tea dance, the staff did an excellent job with the food and entertainment – I am looking forward to the next one – a very successful event’ and ‘ I would like to say how grateful I am to everyone for the way the residents are looked after and I thoroughly enjoyed the tea dance. Relatives who commented said that ‘we always come to the functions – they are very good’. The team actively encourage families and friends to visit residents at the home and they are invited to events throughout the year. The manager plans to develop more links with the local community over the next twelve months. The team are holding a fete in the summer months. Relatives who commented said that they were ‘always welcomed and offered tea and biscuits’. Residents spoken to say that staff in the home respected their wishes. Information on advocacy is available on display in the home. Since the last inspection the home has employed a new chef, consulted with residents on the menus and made changes. Residents spoken to were very happy with the meal service in the home and it was possible to take lunch with two residents and the meal was very good. Appropriate and sensitive help was seen to be given to residents and the tables were nicely laid and condiments available. Meal times have also been changed in response to comments from residents. One relative said that the team had ‘bent over backwards to help her relative in relation to meals’. Records are in place that records each resident’s intake well. This also shows the range of meals available. Residents are having choice as records reflect this – especially at teatime. A variety of choices are available for breakfast and a cooked breakfast is regularly offered. Overall a very varied menu. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents can be reassured that their concerns would be listened to and dealt with effectively. Staff are trained and systems are in place to help ensure the protection of vulnerable adults. EVIDENCE: The home has a satisfactory complaints procedure in place, which is available on display in the home and in the service users guide. Residents and relatives spoken to knew about the procedure and whom they would speak to in the first instance. On inspection, the manager keeps very good detailed records of all concerns at every level. The majority of complaints were seen to be minor and dealt with promptly. The manager in her annual quality assurance assessment still feels that the team could improve by understanding relatives concerns more, however minor they may be. Relatives spoken to say that they were happy with the complaints procedure. The home has a satisfactory adult protection procedure in place and this includes local guidance. Training records show that all staff have received training in adult protection and the manager shows a good understanding of such issues. Cavendish Residential Care Home Limited DS0000062449.V344619.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. 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 clean and well maintained. Changes made to the facilities are generally resident led and their input is valued, giving positive outcomes for residents. EVIDENCE: A partial tour of the home was undertaken. The home was seen to be very clean and well maintained with no odours noted. Since the last inspection the ground floor communal areas and some bedrooms have been decorated. There are plans this year, to upgrade the main bathroom downstairs and a new boiler is to be fitted. There are also plans to replace more carpets, replace some furniture and bedding. The home has a large secure garden to the rear, which gives good privacy. This is a pleasant area to sit and team at the home plan to expand the vegetable garden so that residents can have input should Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 17 they so wish. Residents have been able to personalise their rooms and the team are introducing good signage for doors etc. to help residents with varying degrees of dementia. The manager in her annual quality assurance assessment states that they could encourage residents more to be involved in the decoration choices for their rooms. Following input from residents, the team have moved the lounges around, so now there are two separate lounges allowing for a quiet lounge should residents so wish. This gives a more homely environment and there is now only one television in each room. Arrangements in relation to fire safety were inspected in relation to the maintenance and testing of equipment and completion of a risk assessment. These were found to be in order and up to date. A recent fire officers’ visit stated that fire safety arrangements at the home were reasonable and gave the home a list of minor works to be done. New infection control policies have been introduced and these were satisfactory. Nearly all the staff have received training in infection control. Cavendish Residential Care Home Limited DS0000062449.V344619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team at the home are now stable and their knowledge base is developing well under the guidance of the new manager. EVIDENCE: Since the last inspection, there have been significant changes in the care staff team and a new manager has been appointed. This has brought about positive changes in the home, which now has a more relaxed homely atmosphere and the staff are more content. Staff shifts times have been changed in relation to resident need and all staff are now awake at night. Staffing levels are three during the day shifts and the manager, who works flexible hours and does undertake work on the floor as well as the office. Two awake staff are provided at night. NVQ qualifications are encouraged and 8 out of the 13 care staff have achieved NVQ level 2. The rest of the staff will be commencing the qualification this year. Recruitment procedures at the home are sound and administration improvements have been made to the staff files. Files inspected were found to contain all the required checks and documentation. It is still recommended that the documentation show that gaps in employment have been explored Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 19 and the manager should evidence that staff have been issued with the GSCC Code of Conduct. New staff undertake the Skills for Care induction programme and records to evidence this were available for inspection. Training records show that the home has an busy training programme for its staff and this year staff have attended training in food hygiene, care planning, fist aid, malnutrition screening, diabetic blood monitoring, fire safety, dementia care management, health and safety, infection control and manual handling. The manager reports in her annual quality assurance assessment that she is continuing to work on identifying staff training needs through supervision and appraisal. Staff spoken to are very keen to participate in training provide at the home. Cavendish Residential Care Home Limited DS0000062449.V344619.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. 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 management of the home is sound and work is being done to develop the staff team and the home in the best interests of residents. EVIDENCE: The new manager has settled well into the home and is working with the proprietor to develop the business and the services and facilities offered. She has continued to develop the staff team and has made improvements to the delivery of care and record keeping at the home. At the current time she has yet to be registered with the CSCI and this must be attended to. Staff meetings are held and records show that a wide range of subjects are covered. Relatives and residents meetings are also now held and minutes are kept. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 21 Residents meeting minutes show a good attendance and comments are welcomed from residents on all aspects of life in the home. The proprietor meets with the manager regularly and completes comprehensive reports under Regulation 26, which also include feedback from residents. These reports were seen to be very objective and open with a range of comments from residents. Action points raised were also followed up. The proprietor and manager have a quality assurance system in place, which consists of a full audit of all systems and services. This was completed in March 2007 and records show that the manager has dealt with any action points raised. The team also undertake regular audits of the medication and health and safety. Feedback forms have been developed for relatives that have recently been sent out and the home have yet to receive any back. Since coming into post the manager has also completed short pieces of work, obtaining feedback from residents on different aspects of the home, for example, mealtimes and menus and the layout of communal areas. Residents’ spoken to said that ‘They look after me very well and I am quite happy at the home and don’t want to go anywhere else’ and ‘ I feel well looked after, the food is good and the staff are very nice’. One relative who commented felt that their relative ‘is quite content at the home’. The team hold monies on behalf of many of the residents in the home. The manager has introduced a new system whereby residents and relatives can have a printout every month of the activity on the account. The system was checked and found to be in order with receipts available. A two-signature audit system was about to be put into practice at the time of the inspection. The home has a health and safety policy in place and this was up to date. Accident records were checked and seen to be detailed and followed up where required. The incidence of accidents at the home is low. Random sampling of maintenance and safety certification for equipment and fixtures in the home were seen to be in order and up to date. Cavendish Residential Care Home Limited DS0000062449.V344619.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 2 X X X 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Cavendish Residential Care Home Limited DS0000062449.V344619.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. 1. Standard OP3 Regulation 15 Requirement Timescale for action 30/08/07 2. OP7 15 3. OP7 15 4. OP31 8 Pre-admission assessments must be completed fully and contain sufficient detail and resident input where able. Care plan reviews need to be 30/09/07 resident led and the team must continue to try and involve residents and their relative in the care planning process where possible. Social and behavioural care 30/09/07 plans need to be in place where appropriate and social histories should be completed and involve the resident or their relative where possible. An application to register the 30/08/07 manager must be submitted. 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 Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 24 1. 2. 3. 4. 5. OP1 OP7 OP8 OP29 OP29 Consideration should be given to the format of the service users guide so it relates to residents needs and abilities. Consideration should be given to developing a more person centred approach in the care planning system, especially in relation to the care of people with dementia. Risk assessments, completed for residents, should link into the care planning process, so that the management of the identified risk is clear. Interview records should allow for the interviewer to evidence that gaps in employment have been explored with applicants. Records should evidence that staff have been issued with the GSCC Code of Conduct. Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Cavendish Residential Care Home Limited DS0000062449.V344619.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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