Inspection on 05/06/06 for Home Close

This inspection was carried out on 5th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Home Close 20/05/08

Home Close 25/05/07

Home Close 07/12/05

Home Close 17/05/05

Home Close 22/11/04

Home Close 25/05/04

Home Close 08/03/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Home Close Home Close Cow Lane Fulbourn Cambridgeshire CB1 5HB Lead Inspector Shirley Christopher Key Unannounced Inspection 5th June 2006 10:00 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 Home Close DS0000015159.V291425.R01.S.doc Version 5.1 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. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Home Close Address Home Close Cow Lane Fulbourn Cambridgeshire CB1 5HB 01223 880233 01223 881728 homeclose@abbothealth.com 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) Home Close Ltd Nicola Malthouse-Hobbs Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of services users to be accommodated at any time who require nursing care must not exceed 20 7th December 2005 Date of last inspection Brief Description of the Service: Home Close is a purpose built home situated in attractive grounds in a quiet lane close to the centre of the village of Fulbourn. The accommodation is arranged in flats. Each flat has a kitchenette and a lounge area. There is a large communal lounge/dining room on the ground floor. The service user accommodation is on two floors with the upper floor being accessed by a passenger lift. The home provides care for older people with both social and nursing care needs. There is a day centre on site and the home has ambulance bus transport available for outings. Fees for the service range from £530.00 to £740.00 a week. Extras are charged for additional items such as chiropody and hairdressing. The home is currently being extended and the CSCI has received an application to register an additional four bedrooms. This application is currently being processed. Further building work is going on in the grounds of Home Close. A twentybedded unit is being built and an application will only be made to the CSCI once the building work is completed and all the other relevant authorities have inspected the new build. There is some level of disruption to the existing residents and a number of residents have been moved, (following consultation) to other units. A new manager has been registered by the CSCI following a successful fit persons interview in May 2006. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over two days. The first day of inspection was the 17 May 2006 and this inspection was announced. On this day the inspector did some evidence gathering. This included looking around the home, observing care practices and talking with staff and residents. A pre inspection questionnaire and service user feedback forms were left at the home and the manager was asked to get the relevant parties to complete the paperwork within a fortnight. A second unannounced inspection was undertaken on the 5 June 2006 and commenced at 12.00 pm. A further tour of the home was conducted and the lunchtime meal was observed. Additional staff and residents were spoken to and the inspector sat through both staff handovers. Some records were inspected and feedback was also provided through completed service user questionnaires and the pre inspection questionnaires. The feedback received was positive, but it was acknowledged that there has been a lot of changes over recent months, including additional building work, and a recent appointment of a new manager. There has also been a change in ownership. Improvements have been identified, but there is some work to do particularly around improving the care plans and other records. During this inspection a serious concern was identified around unsafe recruitment procedures. The inspector will go back to the home to check compliance with this requirement and will also look for evidence of how the other requirements are being met. The home is registered to provide care to people over the age of 65. Service users who have a formal diagnosis of dementia as assessed by a psycho geriatrician must not be admitted into the home until an application has been submitted to, and agreed by the CSCI. Operating outside the conditions of registration is an offence under the Care standards Act. Several residents files inspected indicated that they had dementia. What the service does well: The accommodation was maintained to a high standard, despite the obvious building work. The home employs a full time activities coordinator and everyone spoken to said that there is a full and varied programme of activities, both in house and in the local community. There is also a day centre on site, which is well used. The food was said to be excellent and the mealtimes were observed. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 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 Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is ‘good’. This judgement has been made using available evidence including looking at resident’s files, pre admission assessments, contracts, statement of purpose, service user guide, service user feedback forms and discussion with residents and staff. Adequate admission procedures are in place, but the home must ensure that the home continues to appropriately meet residents needs and this is clearly documented. EVIDENCE: A copy of the homes statement of purpose and service user guide was readily available and although this had been updated recently, it needs to be updated again because of the recent changes to the homes registration. The inspection reports are available and are kept at the main desk. The manager confirmed that pre admission assessments are completed before residents are admitted to the home. Evidence of this and other health care professional assessments were seen on file. Residents are able to look round the home before deciding if Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 9 it is right for them, but realistically the choice is often made by a relative. Some residents who completed a service user feedback form stated they had looked around the home. The home is able to provide respite care and has a well attended day centre, so residents may have experienced the home before becoming a permanent resident. A copy of the contract was inspected. The home needs to provide clearer evidence of how they are meeting residents’ needs. Some evidence was provided through discussion with residents and staff but poor record keeping, which did not take into account residents’ views is a concern. The manager must ensure that that the home is registered to provide care to all of the residents accommodated and that the staffing numbers, skills mix and training is sufficient to meet these needs Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is ‘poor’. This judgement has been made using available evidence including looking at resident’s files, other records, such as the accident forms, general observation, service user feedback forms and discussion with residents and staff. Through discussion and observation standards of care are very good, but poor record keeping does not provide clear evidence of this. EVIDENCE: The manager stated that new care plans were ready to be implemented and that she was fully aware of the shortcomings of the current documentation. She stated that residents care plans would be updated gradually and staff would be trained in the implementation of the new care plans. Three care plans were inspected and showed no evidence of consultation with residents. They did not clearly describe residents preferred routines, lifestyles or life/family histories. Where needs had been identified, the language used was ambiguous, such as ‘needs assistance with all personal care’, with no indication of residents’ strengths and support needs. Daily notes were equally ambiguous, example being, ‘care given as per care plan’. Social needs were poorly Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 11 described and risk assessments were not updated regularly. Care plans were not always updated where a concern had been identified, such as weight loss due to poor eating patterns or a change in mobility. The management of falls was also a concern, with poor manual handling assessments and no clear evidence of what preventative measures to reduce falls had been put in place, such as a falls register, falls assessment and staff training in falls prevention. The home employ trained staff to meet the health care needs of residents and said they had a good rapport with the District nurses, who carry out specific tasks for the residential residents. There is a weekly GP surgery and evidence was provided of other health care professional involvement, with regular chiropody and eye care being provided at the home. Medication records were not inspected, but discussions were held with the manager and trained staff around the safe administration of medication. Medication is given out by trained staff and designated staff who have been appropriately trained. Some observation took place of the lunchtime medication round and medication was being appropriately administered. Observations on the day were encouraging. Care staff were positive and had developed good relationships with residents. Residents spoken to stated that the majority of staff were excellent and their privacy and dignity were respected. Residents have locks for their bedroom doors on request and a lockable space in their bedroom. Staff have received training in bereavement and residents’ last wishes were recorded on the files inspected. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is ‘excellent’. This judgement has been made using available evidence including: looking at resident’s files and other records, general observation, service user feedback forms and discussion with residents and staff. The home has an excellent programme of social activities and residents’ dayto-day experiences in the home were mostly positive. EVIDENCE: The home has a full time activities officer and this is a real strength of the service. Activities are planned in advance and take place on all the units. Residents spoken to confirmed a wide range of activities, in which they participated and clearly enjoyed, both in house and in the local community. The home has its own transport and trips are planned throughout the year, but mainly in the warmer weather. Examples given were the local garden centre, and the Newmarket horse racing events. The home has outside entertainers once a month. Some of the residents stated that they go into the garden, but it was acknowledged, that this is difficult at the moment because of the ongoing building work. Residents asked how they knew what was going on and they confirmed that there were notice boards confirming activities, regular residents meetings and daily menu boards. Photographic evidence was seen of Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 13 the range of social activities provided and there was some artwork on display around the home. The home also has a thriving day centre which some of the residents in the home use, although it tends to be used primarily for elderly residents living in the community. Residents stated that relatives were welcome any time, although none were met during the day of the inspection. Relative questionnaires are distributed yearly to establish what their views of the service are. Evidence of this was not inspected. Residents spoken to appeared to have a lot of choice and flexibility over their lives and their wishes respected. They were appropriately consulted about every day wishes/routines, although this was not recorded very well. One resident said she is told not to use her call bell to ask for help to go to the toilet by some carer when she feels she needs to because she feels she is at risk of falling. This was cited in a questionnaire. Many residents spoken to attended the residents meetings and were aware of how and who to complain to about any aspect of the service. Questionnaires are also distributed as part of the homes quality audit system. The inspector entered the kitchens at lunchtime and spoke to the chef. The chef prepares homemade food and takes it personally to the individual units and is therefore aware of what the residents do and do not enjoy. The feedback about the food was excellent and menus displayed a wide variety, with snacks and drinks readily available. One resident said they would like more choice, another said they would like more chips. Individual units have small, self-contained kitchens, which are used for preparing breakfast, snacks and drinks. One resident said drinks are not available throughout the night, although the manager confirmed that drinks are always available. Fresh fruit was being taken round to the units on the day of inspection. Observations of the mealtime were observed on two separate units and staff supervision was appropriate. Units have small dining rooms, which enable small groups of residents to sit together and to converse over their meal. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is ‘good’. This judgement has been made using available evidence including looking at policies and procedures, service user feedback forms and speaking with the manager and care staff. EVIDENCE: The home has appropriate policies and procedures in place for dealing with complaints and adult protection issues. The majority of staff have received training on adult protection, although there were some gaps. It was suggested to the manager that key staff such as the maintenance person and the administrator have some training in adult protection. Some residents stated that they did not know who to complain to and some stated they would complain to a family member. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is ‘good’. This judgement has been made using available evidence including: observation and a tour of the home. The organisation produces literature, which clearly explains the facilities in the home. These were inspected also. The accommodation is fit for purpose and is divided up into a number of smaller, self-contained units, which provides a more homely atmosphere for residents. EVIDENCE: The home was well maintained and clean. Some concern has been expressed about the effect that the ongoing building work is having on the residents’ quality of life at the home, including noise and constant activity. Some areas of the home are affected, such as kitchen and living areas being temporarily out of bounds, although an effort is being made to avoid disruption. Several residents have recently been moved from one unit to another unit, which has Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 16 caused them some distress as evidenced through discussion with them and as discussed in staff handover. A tour of the home was conducted and several observations were made. The home is divided up into individual units, which are individually staffed. Storage is an issue, but the building work was a contributory factor to this. Most areas of the home were well decorated, but some paintwork/bathroom doors were scuffed, caused by wheelchairs. Residents’ bedrooms were attractively furnished and well maintained. Some bedrooms have en-suite faculties. One resident’s bedroom door was propped open and the wedge was removed and the manager informed. Another resident had the alarm cord trailing across the bedroom. This was a trip hazard. The gardens were only seen from the windows and access is limited because of the building work, but the gardens are secluded with large lawned areas and borders with shrubs and flowers. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including discussion with staff, the manager, service user feedback forms and from the pre inspection questionnaire. Staff recruitment procedures must be improved upon to ensure residents’ safety is paramount. EVIDENCE: The inspector sat through two staff handovers and spoke to staff individually. This included the manager, senior staff and care staff. The administrator, cook and maintenance man were also spoken to. The feedback received was generally positive and the observation of staffs’ care practices and their relationship with the residents was good. A number of issues were discussed and feedback about the training in the home and the level of staff support from supervision to team meetings, was felt to be good. Minutes of staff meetings were seen and were inclusive of the whole staff team. Most felt that the manager had made good inroads in terms of bringing about service improvements. Residents raised no concerns about the quality of the staff, but felt that the quantity of staff was sometimes insufficient. Several residents cited this on the day of inspection and through the service user feedback forms that were completed (13.) Some residents said that there was insufficient staffing, particularly in the afternoon. This was echoed by some staff and was attributed mainly to staff going off sick at short notice. Staff sickness is closely monitored. The question of staff morale was discussed and was generally felt to be improving, although there have been an awful lot of changes in the home Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 18 before the appointment of the recent manager and some staff referred to an ‘in-house’ staff culture, which was being challenged. Monthly rotas were requested and the inspector saw no evidence of low staffing numbers, but was concerned by comments made. The registered person has been asked to review existing staffing as part of their ongoing application for more beds and as residents needs are reassessed. At the moment the home has 24 of care staff with NVQ or equivalent. They also have eight full time registered nurses and 4 bank staff who are registered nurses. In the past they have had adaptation students and currently have two student nurses. Most staff spoken to stated that all their mandatory training was up to date, although some gaps were identified. Trained nurses have particular areas of specialisms, for which they are the lead contact and are given regular training for. The staff induction programme was seen and initially covers health and safety, moving and handling, principles of care, first aid and the prevention of abuse. It is linked to the TOPPS standards. Only a small percentage of staff have first aid traing at present. Staff supervision is provided regularly according to care staff and the manager although no other evidence of this was requested. The manager was asked for two staff files of staff recently employed. These files were unacceptable. No interview notes were seen for either person and one person had not been employed for a year or more and had no experience in care. The manager stated that this was explored at interview, but there was no evidence of this. One file had all the necessary pre requisite checks, other than proof of identification. The other staff file had the necessary checks in place but these were dated after the person had been employed by the home. The manager confirmed that POVA clearance is processed before employment through Abbots Health care, but no evidence of this was seen. The person was therefore working before a clear CRB and two satisfactory references. The manager confirmed he was supervised. An immediate requirement was made in regards to this breech of regulation. A number of overseas staff are employed at the home and the manager must ensure that all staff have the necessary prerequisite skills for the job. This was discussed with the manager after a resident had cited a problem with a language barrier. She gave a clear example of when she needed her nebuliser to help her breath and could not make herself understood. This heightened her anxiety making her breathing worse. The manager confirmed staff would be offered English lessons, where this was identified. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is ‘good’. This judgement has been made using available evidence including discussion with the maintenance man, the manager and from the pre inspection questionnaire. The home is developing internal quality assurance systems and currently provides regular forums for discussions for staff, residents and relatives. EVIDENCE: The manager has recently been registered with the CSCI after a successful interview. She has only been in post a short period of time but has made significant progress and has identified a series of priorities. She is suitably qualified and experienced and has previously been registered with the CSCI in the past. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 20 Staff spoken to felt that they were well supported through regular supervision and staff meetings. The home is developing its internal quality audit system, but as the home has had a recent change in ownership who have been in place for less than a year this has not been properly formalised. Resident/relative questionnaires are circulated annually and will be circulated in July and findings/ improvements discussed and published. The current quality audit focuses on a risk analysis of the building. Relative and separate resident meetings are also held. Finances were seen in respect to residents’ monies only. The home holds a small amount of money on behalf of the residents, to pay for small items such as hairdressing and chiropody. The manager confirmed that she has input into the homes budget and said she is able to be flexible about the staffing levels, and bring in bank staff if required. The homes accounts are produced annually and are independently audited. Copies of the forecasted accounts would have been provided to the CSCI as part of the company’s registration with the CSCI, less than a year ago. The home has a full time maintenance person who is well qualified and has relevant experience and qualifications. A sample of maintenance records were inspected and were satisfactory. The pre inspection questionnaire also gave details of when servicing and maintenance has been carried out. The manager produced the homes policies and procedures, which are easily accessible and are being regularly updated. Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 21 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 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation CSA 2000 Requirement Timescale for action 30/06/06 2. OP4 14(2)(a) (b) 15(1)(2) 3. OP7 The home must operate within its current certificate of registration. The registered person must apply for a variation to the homes main registration category in respect of residents with a formal diagnosis of dementia. The registered person must 30/06/06 demonstrate how the home is continuing to meet residents’ needs. The registered person must 30/06/06 ensure that care plans contain sufficient detail to enable carers to meet the individuals’ needs and these should be reviewed and updated at least monthly. This is a previous requirement and the timescale of 30/01/06 has not been met. The registered person must ensure that residents’ health care needs are properly documented and needs updated. Measures must be put in place to ensure residents identified as ‘high risk’ benefit from a DS0000015159.V291425.R01.S.doc 4. OP8 12(1)(a) (b) 30/06/06 Home Close Version 5.1 Page 23 5. OP27 18(1)(a) 6. OP29 19(1)(a) (b) cohesive strategy to reduce the level of risk. Staffing levels must be kept 30/07/06 under review and be increased when the number of registered places increases. The registered person must 05/06/06 ensure that all the pre requisite checks are in place before the employment of a new member of staff. An immediate requirement was made in respect of this at the time of the inspection. The registered person must 30/07/06 ensure that all staff training is up to date. Evidence of the contents of the training must be available. 7. OP30 18(c)(i) 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 Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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 Home Close DS0000015159.V291425.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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