Inspection on 18/04/06 for Royal Cambridge Home

This inspection was carried out on 18th April 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

Royal Cambridge Home 18/10/07

Royal Cambridge Home 18/10/05

Royal Cambridge Home 04/05/05

Royal Cambridge Home 14/09/04

Royal Cambridge Home 07/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Royal Cambridge Home 82-84 Hurst Road East Molesey Surrey KT8 9AH Lead Inspector Denise Debieux Unannounced Inspection 18th April 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 Royal Cambridge Home DS0000013775.V290031.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. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Royal Cambridge Home Address 82-84 Hurst Road East Molesey Surrey KT8 9AH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020-8979 3788 Royal Cambridge Home for Soldiers Widows Mrs Irma Odette Yarnell Care Home 30 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (1) Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The age/age range of the persons to be accommodated will be: 65 Years and over. The gender of those accommodated will be: Female Of the 30 (thirty) service users accommodated, up to 5 (five) may fall within the category DE(E). Of the 30 (thirty) service users accommodated, up to 2 (two) may fall within the category PD(E). Of the 30 (thirty) service users accommodated, up to 1 (one) may fall within the category SI(E). 18th October 2005 Date of last inspection Brief Description of the Service: The Royal Cambridge Home was founded in 1851, originally to provide a home for the widows of NCOs and private soldiers in the British Army. The home is now a registered charity and accepts applications from any widow whose husband has served in the ranks and also from women who have themselves served in the regular, territorial or reserve army. Care and accommodation is provided in single bed-sitting rooms in the two Victorian houses that are interconnected by a corridor link of more modern rooms. The property is situated in large attractive gardens near to Hampton Court. There is ample car parking space available on the site. Service users are encouraged to maintain their independence in a comfortable environment. Personal care is given when service users are no longer able to care for themselves, without restriction to the rights of the individual and with respect to the service users own chosen lifestyle. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 8.25 hours and was carried out by Denise Débieux, Regulation Inspector. Mrs I. Yarnell (Registered Manager) and Ms Mary Lynn Smyth (Administrative Assistant) were present as the representatives for the establishment. A tour of the premises took place. Four of the twenty one service users were spoken to at length, with a further five service users and eight on-duty staff being spoken with during the tour. Some of the comments made to the inspector during the visit are quoted in this report. The service user contracts, policies and procedures, staff training log, activity records and staff recruitment records were all sampled. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this visit. What the service does well: What has improved since the last inspection? Policies and procedures have been revised and updated and the provision of staff training has been increased. Required maintenance work in the kitchen has been completed and the ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 6 Service users spoken with all mentioned their pleasure at the increase and variety of available activities. They also expressed their relief that the uncertainty over the future of the home has now been resolved and that they will be able to continue living at The Royal Cambridge. 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. Royal Cambridge Home DS0000013775.V290031.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 Royal Cambridge Home DS0000013775.V290031.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): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s written terms and conditions document has been revised and now contains all required information. Each service user is only admitted to the home following a needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: At the previous inspection a recommendation was made that the service users’ contracts include their room number. This has now been done and the previous recommendation has been met. The care plans sampled all contained detailed assessments of the service users’ needs and included information regarding their preferences and previous likes and dislikes. One service user spoken with stated: ‘‘I only have to ask, the staff are very helpful’.’ Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 9 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 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: Care plans sampled were comprehensive and clearly set out actions which need to be taken by care staff to ensure that all aspects of the health and personal care needs of the service users are met. These care plans were very detailed and included the assistance required, with emphasis placed on the way the service users want their care to be provided. Members of staff spoken with were enthusiastic about the new system and care plans and felt that it helped them to provide the best service they could. Care plans are regularly reviewed, with the service user fully involved and signing to indicate their agreement. Daily notes are kept that reflect the care given and any changes or new concerns are recorded and acted upon. The staff are to be commended for their work in this area. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 10 During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. One service user spoken with said that, if you wanted something ‘you only have to ask’ with another saying ‘our staff are lovely’. All service users confirmed that they felt fully involved in planning their care and that their needs were being met. The medication administration records, medication storage, policies and procedures were all sampled and found to be in order. Service users that wish to handle their own medications are assisted to do so, based on a risk assessment, and lockable storage is provided in their room. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 11 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided by the home are varied, well planned, and include contact with the local community both within and outside the home. Contacts with family and friends are encouraged. The meals in this home are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The activity coordinator has been in post for a year now and works two days per week. She meets with new service users to gather information regarding their previous hobbies and interests and these are recorded. The activities offer choice and variety and the home are continuing to look for ways to expand the activity programme. The manager mentioned that she is exploring the possibility of introducing wine tasting (to include non-alcoholic wine) and is also looking into the possibility of someone suitably qualified to come to the home to offer T’ai Chi classes for those who would want to and be able to participate. All service users spoken with were enthusiastic about the new activities offered, with one saying that ‘I love her coming (activity co-ordinator) I like the exercises so much I do them in bed too’. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 12 Two service users did mention that, while they enjoyed the activities offered, they would like the bingo to be once a week, and for a longer time, instead of once a month, this comment was passed, with permission, to the manager. A recommendation was made in the previous report that the activity coordinator develop individual activity care plans for each service user. This has not yet been done and the recommendation is carried forward to this report. The possibilities of the care staff working with the activity co-ordinator to complete this work was discussed with the manager. Local community involvement is varied and includes local clergy, boat club, nursery, schools and brownie pack. The lunchtime meal was taking place during this inspection. The food was well presented with service users commenting that the meals were nice and varied. The meal was steak pie with all service users saying how much they had enjoyed their meal. All service users were complimentary about the meals and choice offered with one service user saying that the meals were ‘first class’. All service users said that the chef will always prepare an alternative to the main course, if requested. During the meal the atmosphere in the dining room was pleasant and relaxed, with ample staff available to offer help and assistance as needed. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 13 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. EVIDENCE: There have been no complaints to the home or to CSCI since the last inspection and all service users spoken with were aware of who to talk to if they were unhappy with their care. The manager and two of the care managers have attended the Surrey course on the protection of vulnerable adults and the latest version of the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults is available in the staff room. All staff spoken with during this visit were aware of the procedure to be followed in the event of an allegation and the majority of staff have now attended training. Training issues are dealt with in more depth in the Staffing section of this report. The previous recommendation and one of the two requirements made at the last inspection have now been met and the remaining requirement, which has almost been met, has been carried forward with a limited extended timescale. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 14 All service users spoken with said that they felt safe at the home with one commenting that she felt very safe. Royal Cambridge Home DS0000013775.V290031.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: During the tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and grounds. Many areas, including hallways, the hairdressing room and some personal bedrooms having been recently painted and work was underway on redecorating bathrooms. The grounds looked neat and tidy and the lawns had been recently mowed and garden furniture set out in preparation for warmer weather. On the day of the visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 16 All service users expressed their satisfaction with the accommodation offered by the home with one service user saying that her room was ‘lovely, I love the view’. Royal Cambridge Home DS0000013775.V290031.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets service users needs. The home must take steps to ensure that service users’ safety and well-being is protected by the staff recruitment practices. Lack of a clear staff training and development programme and lack of clarity regarding the staff training required, is potentially placing service users at risk of harm. EVIDENCE: The staffing at the home comprises one care manager and three care assistants from 7.30am until 8.30pm, the night shift is covered by two care assistants with one care manager on call on the premises. One service user commented ‘They do everything you need and in a nice manner’. The inspector was advised that, of the fifteen care staff, nine have now completed their courses in National Vocational Training (NVQ) level 2 or above and are awaiting external verification. The staff spoke well of the course and some were hoping to be offered the opportunity of taking their studies further. All interactions between the staff and the service users during this visit were seen to be caring and respectful. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 18 The home has a close and stable staff group and does not use agency care workers. The recruitment files for all staff employed at the time of the inspection in October last year were sampled at that time and found to have all required information and documents. It is now the practice of the home that no new staff commence employment without an enhanced Criminal Records Bureau (CRB) certificate and having their details checked against the Protection of Vulnerable Adults (POVA) list. Two of the files for the most recent new employees were sampled during this visit and contained proof of identity and written references. However, both application forms had unexplained gaps in employment, the members of staff had not given a full employment history, there was no verification of the reasons the persons had left previous care positions and on one file the home had failed to obtain a reference relating to the person’s last period of employment which involved working with vulnerable adults. The registered persons must ensure that the home’s recruitment procedures are compliant with Regulation 19 and Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 and requirements have been made. At the previous inspection four requirements were identified regarding staff training. Two requirements had been carried forward from earlier inspections and two were new requirements. These requirements were reviewed at this visit and the following found: • The majority of staff have now received training in the Protection of Vulnerable Adults. • Work has begun on developing individual training profiles and assessments for each individual staff member. The manager is in the process of identifying what training the staff have had and the dates the training was received. • Numerous training sessions on mandatory safe working practices have been arranged for the staff and the majority, but not all, have now attended the required training. Others had received training in the past but are overdue for their mandatory updates (i.e. one staff member had not had a manual handling update since 1999). • A staff training and development programme has not yet been developed. The inspector was advised that, following the last inspection, the management committee had decided to employ an administrative assistant whose specific role would be to work with the manager in modernising the administrative systems at the home. The new assistant recently took up her position and has been instrumental in getting the new, modern computer system up and running. The manager stated that, since the last inspection, in addition to the day to day running of the home, she has been concentrating on sourcing and organising training for many of the staff, getting to grips with the new computer system and inducting the new administrative assistant. The Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 19 manager feels that she is now in a position to concentrate on developing a comprehensive staff training and development plan and completing the work required to meet the requirements made, and carried forward, from previous inspections. However, in order for this work to move forward and be completed it is imperative that the manager and her assistant make themselves familiar with the training requirements of all relevant and current legislation without delay. The previous requirements remain outstanding and the registered person must provide the CSCI, Eashing office, with a staff training improvement plan setting out exactly how the outstanding requirements will be met in full. The plan must include definite timescales for the completion of each requirement. Following receipt of the improvement plan CSCI will agree dates for the outstanding requirements to be met. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from the clear management approach at the home providing an open, positive and inclusive atmosphere. There is a quality assurance and monitoring system in place that is based on seeking the views of the service users, but the home needs to carry out a service user survey for the year 2005/6. Formal staff supervision needs to be fully implemented to ensure that service users benefit from well supervised and supported staff. Service users’ financial interests are safeguarded by the policies and practices of the home. Policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 21 The manager has been the superintendent of The Royal Cambridge Home for many years and is currently undertaking her Registered Manager’s Award and an NVQ level 4 in care. Service users spoken with all felt that the home is well run, with one service user commenting ‘It is almost like a family group here’. Service users all felt they were listened to and confirmed that action is taken when a concern is raised. The home carried out a service user survey in the year 2004/5 and produced a report and actioned issues that were raised. At the last inspection the inspector was advised that there were plans to carry out a survey for the year 2005/6 by the end of last year. This has not yet been done and a recommendation has been made that this survey is now carried out. The home do not handle financial affairs for service users. However, on occasions when service users want valuables stored securely for a short period of time, the home lock them in a safe in the main office and full details are recorded in a receipt book. The manager and two of the care managers have now completed supervision training. At the last inspection it was noted that formal supervision had been introduced with two care assistants, with plans to carry out formal supervision with all staff over the following few months and then to continue on a two monthly basis thereafter. However, since that inspection the home have not implemented this plan and have not carried on with formal supervision. The previous requirement has been carried forward and the registered person must now ensure that their formal supervision procedure is fully implemented. It was noted, while looking at records of accidents and incidents, that some required notifications had not been sent to CSCI. The manager was shown the CSCI guidance on Regulation 37 notifications on the internet and advised that CSCI must be notified of any identified incidents without delay. This should be done by whoever is the person in charge of the home at the time and not wait for the manager to return. The home has now carried out the work in the kitchen identified at the Environmental Health Officer’s inspections in 2004. During the tour of the home the new work was seen and the chef confirmed that it is now much easier to keep the kitchen clean. There are also plans to install a new dishwasher within the next two weeks. Policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff were observed to be following these procedures on the day of this visit. This standard will be met when the requirement regarding staff training in safe working practices has been fully met. Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 23 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 OP18 Regulation 13(6) Requirement The registered person must ensure that all staff have received training in the protection of vulnerable adults. (Timescale of 18.01.06 not met) The registered person must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for the two staff files identified during this visit. DS0000013775.V290031.R01.S.doc Timescale for action 30/05/06 2 OP29 19(1)(b) 18/04/06 3 OP29 19(1)(b) 30/05/06 Royal Cambridge Home Version 5.1 Page 24 4 OP29 5 OP30 6 OP30 7 OP30 19(1)(a-c) The registered person must Schedule2 ensure that all staff responsible for staff recruitment are aware of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. 18(1)(a) The registered person must (c)(i) develop individual training assessments and profiles for all staff. (Timescales of 07.07.04, 14.11.04, 04.08.05 and 18.12.05 not met) 18(1)(a) The registered person must (c)(i) ensure that staff working at the care home receive training appropriate to the work they are to perform and receive required training and updates in all safe working practices. (Timescales of 04.06.05 and 18.01.06 not met.) 18(1)(a) The registered person must (c)(i) develop and implement a staff training and development programme that meets current legislation and guidelines and includes the following: • Training in all safe working practices • Identified training to ensure the needs of current service users are met • Protection of vulnerable adults training • All staff to have an individual training and development assessment and profile. (Timescale of 18.01.06 not met) 18/04/06 18/06/06 18/05/06 18/06/06 Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 25 8 OP30 18(1)(a) (c)(i) 9 OP36 18(2)(a) 10 OP38 37(1) (a-g) 37(2) The registered person must submit, to the CSCI, Eashing office, an improvement (action) plan, setting out exactly how the outstanding staff training requirements (numbers 1, 5, 6 and 7 above) will be met in full. The plan must include specific timescales for completion of each requirement. The registered person must fully implement formal supervision with all staff. (timescale of 18.01.06 not met) The registered person must give notice without delay, to CSCI Eashing Office, of the occurance of any incident set out in Regulation 37 of The Care Homes Regulations 2001. 18/05/06 18/06/06 18/04/06 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 Refer to Standard OP12 Good Practice Recommendations It is recommended that the activity co-ordinator and staff draw up individual activity care plans with each service user. These care plans should take into account the identified preferences of the service user with particular consideration being paid to any individual needs. I.E. Dementia; physical disability; sensory impairments. (Brought forward from previous report of 18.10.05) It is recommended that the home carry out a service user survey, as last year, and produce a report, with planned actions, on any concerns identified. A copy of the report to be provided to all service users, included in the service users’ guide and sent to CSCI, Eashing office. 2 OP33 Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Royal Cambridge Home DS0000013775.V290031.R01.S.doc Version 5.1 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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