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Inspection on 07/09/05 for Cherry Hinton Nursing Home

Also see our care home review for Cherry Hinton Nursing Home for more information

This inspection was carried out on 7th September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

At the last announced inspection it was recognised that the home has already achieved over 60% of care staff trained to NVQ 2 level or its equivalent. The home does not have a particularly high turn over of staff and at the time of inspection the home was fully staffed. Eight care staff were working on each floor. Care staff were observed as they assisted service users with activities of daily living. Care and support was being offered appropriately in a relaxed, unhurried fashion. The environment is appropriate for purpose and was clean and well maintained with no obvious hazards. Service users confirmed that they made use of the large, landscaped gardens. The manager has been employed at the home for a few years and has considerable experience and makes herself readily available to support the staff and discuss any issues with relatives and visitors to the home.

What has improved since the last inspection?

At the last inspection it was noted that improvements were being made to the homes written documentation, specifically in relation to the service users` care plans. In order to do this, the home were in the process of gathering new information and reviewing existing information held about each service user. A new pre admission assessment form has been designed and the care plan format changed. The manager has written to relatives asking them to give details of the service user`s life history to enable care staff to address more than just their physical care needs. Social histories were felt to be extremely importance, particularly when the service user is unable to express themselves clearly through verbal communication because of illness. The daily records were much improved.

What the care home could do better:

Although some evidence was seen of improved care documentation, which more accurately reflects the high levels of care given by care staff. The records inspected in two instances were very good and in two instances very poor. Care plans had been re written and were much more concise, but evidence of monthly review was not provided either because the plans had recently been implemented or, and through oversight. Evidence that service users are consulted regarding their care plans was poor. Social life histories were sufficient on two files, but inadequately recorded on two other files. Improvements in the risk assessments were identified at the time of inspection. Some staff files did not contain all the appropriate information and this potentially puts service users at risk. A copy of the revised Statutory Instrument 2004 No. 1770 The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 were given to the manager.

CARE HOMES FOR OLDER PEOPLE Cherry Hinton Nursing Home 369 Cherry Hinton Road Cambridge Cambridgeshire CB1 4DH Lead Inspector Shirley Christopher Unannounced 07 September @ 8:00 am 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 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. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cherry Hinton Nursing Home Address 369, Cherry Hinton Road, Cambridgeshire CB1 4DH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01223 210071 01223 413572 N/A Rockley Dene Homes Limited Mrs Doris Bater Care Home 40 Category(ies) of Dementia -over 65 years of age (20), Mental registration, with number Disorder, excluding learning disabilty or of places dementia- over 65 years of age (20), Old age, not falling within any other category (20) Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 June 2005 Brief Description of the Service: Cherry Hinton nursing home is a large purpose built building, just off the Cherry Hinton Road. It provides accomodation for up to forty service users, requiring nursing care or who have a formal diagnosis of dementia. The home provides accomodation on two floors, the ground floor accomodates service users with dementia. Most of the bedrooms are single and all are ensuite. The first floor is for service users with a nursing need. There is a third floor which is used as a storage area, staff area and is where the kitchen is situated. The building is secure and there is a large landscaped garden to the rear of the property which is well maintained and has a large lawned area and mature trees. There is ample parking. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken on the 7 September 2005 at 8:00 am and finished at 12:20 pm. The manager was on duty alongside eight other staff, in addition to domestic, catering and administrative staff. No staff other than the administrator and manager was spoken to as part of this inspection, other than to say hello. Three visitors were met briefly. Seven service users were spoken to about their experiences of life in the home. Four service user care plans, four staff files, staff appraisals, staff supervision and staffing rotas were examined. Resident and staff meeting minutes were seen in addition to the homes quality assurance programme. A new pre-admission assessment and service user guide has been developed and the manager confirmed that the latter is given out to service users and their relatives. No evidence was seen of the new pre admission assessment being used. A tour of the home was conducted but no maintenance records were looked at as part of this inspection. The last announced inspection was on the 20 June 2005 and the reader should refer to this report for a fuller picture of the homes performance as not all the standards were covered as part of this inspection. What the service does well: At the last announced inspection it was recognised that the home has already achieved over 60 of care staff trained to NVQ 2 level or its equivalent. The home does not have a particularly high turn over of staff and at the time of inspection the home was fully staffed. Eight care staff were working on each floor. Care staff were observed as they assisted service users with activities of daily living. Care and support was being offered appropriately in a relaxed, unhurried fashion. The environment is appropriate for purpose and was clean and well maintained with no obvious hazards. Service users confirmed that they made use of the large, landscaped gardens. The manager has been employed at the home for a few years and has considerable experience and makes herself readily available to support the staff and discuss any issues with relatives and visitors to the home. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Although some evidence was seen of improved care documentation, which more accurately reflects the high levels of care given by care staff. The records inspected in two instances were very good and in two instances very poor. Care plans had been re written and were much more concise, but evidence of monthly review was not provided either because the plans had recently been implemented or, and through oversight. Evidence that service users are consulted regarding their care plans was poor. Social life histories were sufficient on two files, but inadequately recorded on two other files. Improvements in the risk assessments were identified at the time of inspection. Some staff files did not contain all the appropriate information and this potentially puts service users at risk. A copy of the revised Statutory Instrument 2004 No. 1770 The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 were given to the manager. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 7 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. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 9 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 standard(s) 1,2,3,4,5 The service user guide has been revised and gives service users the opportunity to decide if the home has the facilities they want. Visits to the home before admission are encouraged. EVIDENCE: Four service user files were inspected and provided evidence that a pre admission assessment is completed before any one moves permanently to the home. Other health and social service assessments are obtained where completed. A number of service users and a relative confirmed that they had seen the home prior to moving in. The manager stated that the service user guide is given out to service users and relatives before admission. There was no evidence to suggest that care staff are not provided in sufficient numbers to meet the needs of service users and the home has a high percentage of adaptation nurses, who are regularly supported and care staff with NVQ level 2 or equivalent. Staff tend to work on designated floors, enabling them to get to know the needs of the service users well. Clinical supervisions are held regularly, as well as six monthly staff appraisals and Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 10 statutory and specialist training is provided. Train the trainer courses are promoted and then training is cascaded down. Intermediate care is not provided at this service. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 11 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 standard(s) 7,8,10 Care staff meet service users’ needs in an appropriate and caring manner. Care records need to reflect the high standards of care provided and records should appropriately address risks to service users health and safety and measures put in place to reduce them. EVIDENCE: Four service user care plans were inspected. Only one service user was asked if she was aware of her care plan and she replied no. Of the care plans inspected, no evidence was provided of service user involvement in either the implementation or the review of the care plan. One relative confirmed that the inspection reports are accessible and she has attended a statutory review of her mother’s care. The manager confirmed that statutory reviews are held for both self-funded and service users funded by social services. Records are kept in a main file and were not inspected. It was disappointing to note that although improvements have been made in terms of service user records, gaps were still identified in the files inspected. All four care plans contained a care plan addressing social needs, an activity chart, which indicated what social activities the service user had participated in Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 12 over a month period. Life histories were also on file. Two service users life stories were very limited and their activity charts did not accurately reflect the number of activities they had participated in. On one file there were photographs of the service user participating in activities and a completed family tree. This was an excellent example. The manager stated that there had been some reluctance on the part of the family or service user to give such information. This of course should be respected, but recorded on file. A new care plan format has been introduced and these go into considerably more detail and cover most aspects of the service users’ routines of daily living, strengths and support needs. They give guidance about managing particular health issues, illness or behaviour. Whilst these were very much improved no evidence of review was provided, either because the plans had been newly implemented, they referred to a new admission or there had been an oversight, in the case of a least one file. Care plans had not been reviewed for at least three months on this file. Other health care records included monthly weight charts, nutritional and Waterlow pressure care charts, risk assessments and moving and handling assessments. Evidence of a collaborative approach to health care was evidenced through the records and the daily recording notes, which provided a positive summary of the main areas of health and social care. The risk assessments seen were poor and should be identified as a specific staff training need. Two were not dated or signed and had no date for review. Another failed to identify specific risks and preventative measures that should be put in place, should a risk be identified. The care plan did identify a specific risk and preventative measures to be put in place, but there was no evidence that the measures were put in place, resulting in an avoidable incident. Following the incident there was no evidence that the care plan or the risk assessment were reviewed accordingly. Requirements have been made in a number of inspection reports regarding the written documentation in the home, particularly around the frequency of reviews, the recording of changed, or unmet need, the dating and signing of documentation, the involvement and consultation of service users in their plan of care. There has been a good attempt to improve the standard of record keeping, but evidence should be provided that all service user files have been audited to ensure consistency of record keeping and to avoid enforcement action being taken in the future. The medication records and medication supplies were not inspected on this occasion. The manager confirmed that they use Boots the pharmacy and they carry out regular, external pharmaceutical inspections. The manager was advised that a pharmacist working on behalf of the CSCI would be carrying out an unannounced inspection. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 13 On the files inspected three out of four did not record service users last wishes/requests and this should be addressed when appropriate to do so. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 14 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 standard(s) 12,13,14,15 Social life histories and care plans identify how social care needs are to be met. The home employs an activities coordinator. The home must ensure that records indicating service user participation in activities are kept up to date. EVIDENCE: A number of service users were spoken and confirmed that different social activities were provided. The home uses the pat a pet scheme, have regular religious services, and the hairdresser visits weekly. Service users stated that they go out into the garden and are taken out occasionally by care staff. Birthdays are celebrated and outside entertainers are brought in. The frequency of activities is recorded on monthly activity sheets, which in themselves cannot be relied on because of poor record keeping. Different events are advertised, but one lady stated that she needed to rely on staff to inform her of what’s on. The manager stated that more posters would be displayed at eyelevel. The home has a member of care staff who is responsible for organising social activities at least two/three times a week. Social care plans and life stories are in place for service users. The home is well equipped with adequate space for social activity, including a large, well manicured garden, and a conservatory, where smoking is permitted and separate lounges. Board games and books were available. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 15 A number of visitors arrived at the home throughout the morning. All were greeted appropriately and the manager has an open door policy to answer any questions they may have about their relatives. Comments from the service users about the food were positive. The chef accommodates specific diets and likes and dislikes. A choice of menus are available and are laminated and left in the dining room. Arrangements are in place to ensure the appropriate supervision of service users at meal times. Breakfast was being served after 9.00 am and included a selection of cereals, toast and a cooked breakfast to be taken either in the main dining room or individual rooms. Dietary supplements were available and weights are monitored at least monthly. Service user choice is reflected in the care plans and through observations. Routines observed were relaxed and unhurried and service users independence was promoted as far as possible. Care staff were complimented for the patience and attentiveness. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 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 standard(s) 16,18 The home has an adequate complaints and adult protection policies and procedures. EVIDENCE: The home has appropriate policies and procedures in place for dealing with complaints and adult protection issues. The manager was unable to confirm that all staff had received up to date training in the protection of vulnerable adults, although some evidence of training was seen. Two members of staff had completed a train the trainer course and the manager confirmed that she would ensure that training is updated. A recent complaint was appropriately recorded. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 The environment is well maintained and homely, with no obvious generic hazards or risks, although risks to individual service users are poorly documented. EVIDENCE: A number of areas of the home were inspected and given the early time of the inspection were still being cleaned. The home was well maintained and cleaned to a high standard without any obvious hazards. A number of personal touches had been added to create a homely feel and pleasant music was playing in one lounge. A new television had been purchased for the first floor and the service users confirmed that they have televisions, telephones and radios in their bedrooms, if they wished. The manager confirmed that bedrooms have a selflocking device, which could be overridden in an emergency. Double bedrooms were appropriately screened. No maintenance records were inspected. The kitchen, laundry room and bathrooms/toilets were not inspected. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 18 Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The home is adequately staffed to ensure that appropriate supervision of service users is provided. Care staff receive appropriate training and supervision. Pre employment checks are carried out, but some gaps were identified, potentially putting service users at risk. EVIDENCE: The staffing rotas provided evidence that appropriate staffing levels are maintained throughout the day/night and the home was fully staffed, except for one domestic post and weekend cook. Staff files provided evidence that staff receive clinical supervision and six monthly appraisals, which look at their training needs and career aspirations. Some evidence of mandatory and specialist training was provided. The manager confirmed that training in the protection of vulnerable adults will be provided to all staff and it is advisory that all staff involved in care planning receive training in the management of risks, in addition to the training already received on care planning. Five staff files were examined and were mostly satisfactory and containing all the required information. One member of staff had been employed on the strength of a CRB obtained whilst in alternative employment. The manager was reminded that they are not portable. The administrator stated that this was in direct contradiction with advice given by a member of staff in the POVA team. A copy of the Statutory Instrument 2004 No. 1770 The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) was given to the manager. She must now take up a new CRB check for this staff Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 20 member. One member of staff’s file did not have a recent photograph. One staff member only appeared to have one personal reference, although the manager was certain that a second reference had been received. Two newly employed members of staff files were inspected; one did not have an induction record on file, (the manager stated she may have taken it home.) A second induction record was largely incomplete. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36 Consultation and involvement of service users is of paramount importance and the home must clearly demonstrate that service users are given every opportunity to participate and have a voice. EVIDENCE: Most of these standards were not inspected on this occasion. Records inspected included four staff files, staffing rotas, supervision records, four service user files, menu records, complaints log and service user guide. Residents/ staff meeting minutes and the homes quality assurance system was also inspected. Staff meetings are held when required, approximately every two months. Residents meetings are held frequently, but are poorly attended. The manager stated that forthcoming meetings are advertised on the board and the frequency of residents meetings are documented in the service user guide. The manager stated that the head office generate five service user/relatives questionnaires every month about different aspects of the home. The results of the questionnaires are used to identify areas of good practice and areas for improvement. Once every couple of years the head office do a Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 22 much larger sample. The manager said that relatives and services users get feedback from the anonymous questionnaires. Results are put on notice boards and discussed at relative meetings. Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 4 x x x x x x STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x x Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 (2) (a) (b) (c) Requirement Care plans must be kept under review and provide up to date information on service users, strengths and needs. Records must be dated and signed. (This is a previous requirement the timescale of the 30 July 2005 has not been met. Service users or a representative of the service user must be consulted with regards to the original care assessment and the subsequent implementation of the care plan. They must be notified of any revisions of their plan of care. Unnecessary risks to health and safety of service users must be identifed and appropriate measures put in place to eliminate and reduce the risk. Records must be kept updated, taking into account any new, changed or previously unidentifed risk. Records must be dated and signed and staff adequately trained in the management of risk. The manager must ensure that she has all the information required by regulation 19 and Timescale for action 30 October 2005 2. 7 15 (1) (2) (d) With immediate effect and for all new admissions . With immediate effect and ongoing 3. 8 13(4) (c) 4. 29 19 (4) (b), 9, 10, 11 and With Immediate Effect and Page 25 Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 5. 30 Regulation relevent schedules including, a 17(2) recent staff photograph, two satisfactory written references, and a CRB/POVA 1st check. 18 (1)(a) The manager must demonstrate that staff are competent. Staff induction records must be completed in full and left on the premises in staff files ongoing 30 October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 12 Good Practice Recommendations An audit of all the care plans should be complete to ensure consistency of record keeping and encourage good working practice. Service users should be encouraged to participate in social activities according to their abilty and choice. Records should accurately reflect their participation in activity and social events should be widely published, rather than service users just relying on staff to inform them of forthcoming events. Training in the protection of vunerable adults should be updated for all care staff. Evidence should be provided that feedback from stake holder/service user questionaires is provided and address how goals are to be achieved. Feedback from service users should be encouraged through discussion groups and their involvement in the implementation and review of their care plans. . 3. 4. 18 33 Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 26 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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 Cherry Hinton Nursing Home I53 I03 S24283 CHERRY HINTON NURSING HOME V247436 070905 STAGE 4.doc Version 1.40 Page 27 - 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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