Inspection on 18/10/07 for Royal Cambridge Home

This inspection was carried out on 18th October 2007.

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

The inspector 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 18/04/06

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 Helen Dickens Unannounced Inspection 18th October 2007 10:15 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.V347092.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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 020 89416897 Royal Cambridge Home for Soldiers Widows vacant post 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.V347092.R01.S.doc Version 5.2 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 April 2006 Date of last inspection Brief Description of the Service: The Royal Cambridge Home was founded in 1851, and provides care for the widows and female dependents of all persons who have served in the Armed Forces. It also includes women who themselves have served in the armed forces. ‘Dependents’ means spouse, civil partner, widow, former spouse, former civil partner, parent, child, step-child, adopted child and qualifying cohabitants. 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. Fees range from £445-£630 per person per week. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Senior Care Manager represented the establishment. A partial tour of the premises took place. The inspector spoke to four residents on a one-to-one basis and talked briefly with many of the remaining residents during lunch. Eight questionnaires returned to CSCI prior to this inspection were also used in writing this report. Two resident’s care plans and a number of other documents and files, including three staff files, as well as risk assessments and maintenance records, were examined during the day. The Annual Quality Assurance Assessment completed by the home prior to the inspection has also been used in writing this report. The Commission for Social Care Inspection would like to thank the residents, relatives, Senior Care Manager, and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: This home offers a very comfortable environment and a happy, friendly atmosphere for residents and staff alike. Maintenance and housekeeping arrangements are very good and residents praised both the housekeeper and the maintenance officer. Care planning arrangements are excellent with good clear care plans, and plenty of evidence that residents had been involved in drawing these up. Those sampled had been regularly reviewed. Staff training is now very well organised with centralised lists of all training undertaken and when this training is due to be renewed. Resident’s views are sought in a variety of ways, including annual and ad hoc questionnaires, and the new suggestions box in the hallway. Many favourable comments were received from residents with one saying they were ‘completely contented.’ There is a new chef at the home who is working hard to provide more home cooked meals, with the emphasis on good nutrition (e.g. home-made soup for Friday evening supper and more fresh fruit puddings) as well as residents favourites such as ‘bacon butties’ for tea. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 6 In addition to the main meals, food items are given out at no extra charge to residents, including a weekly bowl of fresh fruit to each resident’s room – and teabags, coffee, crackers, biscuits and cheese (some residents have their own fridge) etc for those who wish to have them. The housekeeper takes a weekly order for these items and delivers them to resident’s rooms. The home has regard to equality and diversity and has an equal opportunities policy in place. Arrangements are made for residents with differing needs, for example with regard to religion or dietary preferences. The home has been adapted to meet the needs of those with physical disabilities. The current residents are all ladies who prefer female staff to support them with personal care, and this is taken into account by the home when recruiting care workers. What has improved since the last inspection? What they could do better: Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 7 Two Requirements relating to recruitment records are still outstanding and more work will need to be done on this. There needs to be a risk assessment carried out on the laundry as there were washing liquids and powders left out and the door was not locked. There are also a number of recommendations which are listed at the end of this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. No resident moves into this home without having his/her needs assessed and been assured these will be met. EVIDENCE: Two resident’s files were sampled during the inspection and found to contain sufficient detail in relation to their assessed needs. Key areas were covered including communication, mobility and personal care, and these needs were then transferred to each resident’s care plan. Information had been gained from other professionals, including information in relation to resident’s health. Some complimentary remarks were made in questionnaires returned to CSCI including, when asked what the home does well, one visitor wrote; ‘Makes my relative feel at home and takes the worry away from her.’ Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social care needs are set out in an individual plan of care, and their health needs are met. Arrangements for the administration of medication are good, and residents are treated with dignity and respect. EVIDENCE: Care planning is well done at this home and clearly identifies resident’s needs both from the initial assessment, and from subsequent reviews. Resident’s preferences are documented throughout, and they had signed off their care plans, demonstrating their agreement with and participation in, the care planning process. Those sampled in detail, and two others which were briefly scanned, had had regular monthly reviews. The domestic arrangements are excellent at this home and resident’s preferences in relation to their personal bed making, and how they would like their bed changed, including how often, are also noted on each resident’s care plan. Each resident’s file also contained Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 11 relevant risk assessments, for example in relation to pressure sores, falls and moving and handling. Resident’s health needs are assessed when they are admitted to the home and subsequently when their needs are reviewed. Residents are weighed and assessments include needs in relation to nutrition, and bowel care. The home has a good relationship with visiting health professionals including the regular GP, who makes a weekly visit to the home, and the district nurse. The chiropodist also visits the home on a regular basis and a separate room is set aside for this purpose. All visits made by health professionals are clearly documented on resident’s files. Some favourable comments were received from health professionals including ‘Overall I think the care is very good.’ Part of the lunchtime medication administration session was observed. Records were examined and the cupboard and medication trolley were checked. Medication was found to be safely administered, and those residents willing and able to administer their own medication could do so with the appropriate risk assessment in place. The local pharmacist carries out inspections at the home to check on pharmacy arrangements. The member of staff assisting the inspector said the next visit was due and she was asked to follow this up with the pharmacist. Staff were respectful towards residents and were observed to knock on bedroom doors before entering. The AQAA document returned to CSCI prior to the inspection states that existing staff have had customer service training (and all new staff will be given this training), which covers the privacy and dignity of residents. One improvement since the last inspection has been the way staff now greet visitors on entry to the home, but go and ask residents if they would like to have the visitor, before visitors are shown to resident’s rooms. Telephone calls can be made in private. Resident’s care plans identify how they would like their laundry dealt with, and the housekeeper confirmed that each resident has their clothes laundered separately. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to follow social, cultural and religious interests, and are encouraged to maintain family and friendship links. The home continues to find ways for residents to exercise choice and control over their lives. Meals at this home are nutritious and offered in pleasant surroundings. EVIDENCE: The activities rota shows there are activities on 2-3 half days per week; this is in addition to the hairdresser. There are also interests which resident’s follow individually, such as having a daily paper, or attending church groups. Four residents returned questionnaires to CSCI and 3 out of 4 said there were ‘usually’ activities provided at the home. One said that there were activities only ‘sometimes’, but no-one ticked the first option of there ‘always’ being activities on offer. It is recommended that the home review the number of hours of activity provision as it was suggested that a worker visiting the home say 5 afternoons per week, would give residents a lot more opportunities to take part in fulfilling activities. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 13 The home maintains contacts with the local community. Residents use local health services and are in contact with local faith communities. There are good contacts with the Royal British Legion, and also with local schools who visit the home. The administrator said that The Rainbows (baby Brownies) had visited and planted bulbs in the garden. A few residents also attend the local day centre in Elmbridge. Residents are given opportunities to exercise some choice and control over their lives. This was evident from their care plans where they have clearly been asked how they would like personal support and domestic assistance to be given. As mentioned earlier, the home has also started asking visitors to wait whilst staff check with residents if they would like to see their visitors. There have been several resident’s meetings, organised by the residents themselves. This has ceased since the resident who organised these meetings has moved away from the area. Residents who spoke about this were advised to speak with the new manager, expected to start within a matter of weeks, to ask if these meetings could be re-started. There is also a good deal of choice and consultation in relation to food, and this is discussed below under mealtimes. Mealtimes at The Royal Cambridge offer a pleasant dining experience with some residents eating in the main dining room, some in a smaller dining area, and others choosing to eat in their rooms. The main course is a set lunch but residents can have a variation on this if they do not like particular foods. There is a set menu for tea also, but the housekeeper asks every resident every day, exactly what they would like. On the afternoon of the inspection some were having soup, some a selection of sandwiches, and one was having ham and tomato. It was recommended that daily alternatives to the lunchtime main meal be stated on the menu to remind residents that they can have a choice. The chef, who has catering qualifications, has only been at the home for three months but has already changed the menus, introducing mainly home-made meals, including puddings, and with the emphasis on more nutritious meals. He has, for example, introduced a homemade soup for tea every Friday, which is popular with residents. There were some comments from residents about portion sizes, and both the chef and the senior care manager said they would ask residents whether they would like to help themselves to vegetables rather than have these served in the kitchen. Additional food items are given to residents at no extra charge, for example a weekly bowl of fresh fruit to each resident’s room – and teabags, coffee, crackers, biscuits and cheese etc for those who wish to have these in their rooms. One resident said that she always made herself two slices of toast before she went to bed. The housekeeper takes a weekly order for these items and delivers them to resident’s rooms. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their complaints will be listened to, and they are protected from abuse. EVIDENCE: There is a complaints procedure in place but the home’s complaints book showed that no complaints had been received; and there have been no complaints to CSCI about this home since the last inspection. In questionnaires returned to CSCI, residents and relatives knew how to complain if they needed to. The home has introduced a ‘suggestions box’ which is emptied on a regular basis – those suggestions received had been looked at by the home and alterations made or discussed. There is a copy of the Surrey local procedures for the protection of vulnerable adults at this home, as well as their own in-house policy. Since the last inspection the remaining staff who had not had relevant training have received it. The senior care manager was asked to ensure that the in-house policy contained the latest contact details for both CSCI and the local Safeguarding number. It is also recommended that the in-house policy dovetail with the local Surrey policy (e.g. definitions of abuse) in order to avoid any confusion. Shortfalls regarding recruitment, relevant to safeguarding vulnerable people, are covered under Standard 29. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment, which is very clean, pleasant and hygienic throughout. EVIDENCE: The Royal Cambridge offers a very pleasant and homely environment for residents. Those spoken to were pleased with their rooms, and those bedrooms visited were well decorated and maintained and showed that residents had been encouraged to bring in their own belongings. Some residents had large bed-sitting rooms; others had separate bedrooms and sitting areas. Communal facilities are good with pleasant dining rooms and a main lounge with large flat screen TV. There is also a separate chiropody room and hairdressing salon. The ‘library’ currently has a large table down the centre of the room, making it less comfortable for resident’s use. The senior care manager said she was hoping that this room would be returned to being a Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 16 library and quiet room, whilst an alternative downstairs room would be made available for staff training and Trustee Meetings. The gardens are very attractive and well kept. A damp patch on the wall in the corridor near the kitchen has already been treated and the maintenance officer said it would be repainted within the next two weeks. This home is very clean and hygienic throughout. There were no unpleasant odours anywhere in the property. A full-time housekeeper is employed and she is responsible for the six part-time cleaners, the laundry staff, and the chef. The kitchen was visited soon after lunch and found to be very clean and tidy, as were both dried food stores for which the chef was also responsible. Many complimentary remarks were made about the housekeeper and her team, and the level of cleanliness within the home. One resident said she would be happy to be quoted in the report when she said ‘The cleanliness of the place is excellent.’ The laundry was clean and tidy, and the housekeeper said each resident’s laundry is washed separately. Improvements since the last inspection have included introducing the red bag system for soiled laundry, and having an air freshening system installed. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff and they are in safe hands at all times. Significant improvements have been made in regard to staff recruitment practices, but more work needs to be done to ensure the correct information is obtained for each new staff member. Further improvements have been made in relation to staff training and staff are trained and competent to do the work for which they are employed. EVIDENCE: The home was well staffed on the day of the inspection with a documented rota on the office wall. The rota shows there are additional staff at peak times and sufficient domestic staff, including a full-time housekeeper, are employed. Residents commented very positively on the staff at this home, and in particular how well they are looked after and how clean the home is kept. There are currently 25 care staff at this home. Eleven staff are qualified to NVQ Level 2, and five to NVQ Level 3. Therefore the home exceeds the minimum ratio set down in Standard 28 of a minimum 50 of staff being qualified to at least NVQ Level 2. The housekeeper said that two cleaning staff are currently doing an NVQ in cleaning. The chef has catering qualifications and a current food hygiene certificate. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 18 This home has made a number of improvements in recruitment processes following advice and Requirements made at the April 2006 key inspection, and at the September 2006 random inspection; including training for senior staff. Three recently employed staff files were sampled - all had an application form, two references, and pova checks. Two of the care staff had a full CRB, and the third person, who was not a member of the care staff, was working under the supervision of the housekeeper. Both the senior care manager, and one other care manager were spoken to and both were clear about what information was required for new staff. However, one person interviewed six months before being taken on did not have a complete employment history, and one reference appeared to be from a friend. The explanation offered was that this person’s file, compiled 6 months previously, had not been reviewed in the light of the more recent staff training on recruitment. The senior care manager was asked to ensure that staff files were reviewed to make sure that all contained the relevant information. The home should also consult the CRB website for guidance on the storage and destruction of CRB certificates. Staff training has improved considerably since the last inspection with clear evidence that staff have done the essential training courses, e.g. protection of vulnerable adults, infection control and moving and handling. The central training list also highlights when refresher courses are due. All staff have an individual training and development assessment on their file. In addition to the mandatory courses, some additional training has been provided, where this would be relevant to the needs of current residents, for example in relation to dementia. All new staff follow the in-house induction programme, which is currently under review. The senior care manager had already looked at the Skills for Care information on this subject and it is recommended that the home incorporate the Common Induction Standards into their own arrangements. Residents are invited to join in with staff training, and some already have, for example the fire training course. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home is well run in the best interest of residents. Resident’s financial interests are safeguarded and their health and safety promoted. EVIDENCE: The previous manager retired in July and since then the home has been well managed by existing staff. The senior care manager has taken over responsibility for all issues relating to the care of residents, until the new manager arrives on 1st November. Residents were pleased that an appointment had been made as several commented on the absence of a manager in their questionnaires to CSCI. The Trustees have confirmed in writing to CSCI both the start date and the qualifications of the new manager. There are currently clear lines of accountability within the home. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 20 There are a number of mechanisms in place to ensure this home is run in the best interests of residents including monthly Regulation 26 visits on behalf of the provider, a well-publicised complaints procedure, and an annual survey of residents and other stakeholders. The home has introduced a suggestions box in the hallway for residents to comment on particular areas, and a number have been received already. There has also been an ad hoc resident’s questionnaire covering meals and menus, which was undertaken in January. The care manager in charge speaks with each resident each day, and the housekeeper also speaks with each resident in relation to their evening meal choices every afternoon. Some residents choose to keep money in the safe and this is kept in a cash tin with a record of any incomings or outgoings. Two resident’s records were checked and the amount in the cash tin matched that noted in the written record. The Charity has an annual audit and resident’s monies in the office are part of the audit by a firm of independent accountants. Formal supervision for staff is now in place, with all those who supervise others having watched a training video on this subject. All staff have been allocated to a supervisor and records checked on two staff members showed regular, formal and documented supervision was taking place. The housekeeper has overall responsibility for health and safety at this home and a number of procedures and systems are in place to promote the welfare of residents, staff and visitors to the home. There is a maintenance officer who is responsible for all maintenance issues within the home, including safety arrangements in regard to safe water temperatures for residents. He was interviewed and found to be knowledgeable on his responsibilities especially in relation to the prevention of legionella; it is recommended that the home also obtain the Health and Safety Executive advice leaflet on the prevention of legionella in care homes, to check they are following all the correct procedures. Residents commented favourably on the overall maintenance of the home and said the maintenance officer ‘..Is an absolute treasure. If you ask him anything, he is straight onto it.’ All staff have had health and safety training, and fire training. An external consultant has also carried out a fire risk assessment. The home has taken advice from the fire service on an outstanding recommendation to have one extra fire door fitted upstairs and the maintenance manager said they were advised that this was not necessary. It was noted that the laundry door is not lockable yet there are washing liquids and powders left out. It was requested that a risk assessment be carried out on the safety aspects of the current arrangements. Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 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 OP29 Regulation 19(1)(b) Requirement 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). (Timescale of 18.04.06 and 11/09/06 not met.) 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 staff whose files do not currently contain the correct information. A risk assessment must be carried out regarding the laundry area, with particular attention to DS0000013775.V347092.R01.S.doc Timescale for action 18/10/07 2. OP29 19(1)(b) 18/11/07 3. OP38 13(4) (a)(c) 25/10/07 Royal Cambridge Home Version 5.2 Page 23 washing liquids and powders which are left out, and the door which is unlocked. 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 number of activity coordinator hours be increased as discussed in this report to give residents more opportunity to take part in fulfilling activities. It is recommended that daily alternatives to the set lunch be listed on the menu, and that residents be offered the option of serving their own vegetables at the table to avoid past difficulties with portion sizes. The home’s in-house policy should contain the latest contact details for both CSCI and the local Surrey Safeguarding number. It is also recommended that the inhouse policy dovetail with the local Surrey policy (e.g. definitions of abuse) in order to avoid any confusion. It is recommended that advice and guidance be sought from the CRB website in relation to the proper storage and destruction of CRB certificates. It is recommended that the current review of the induction programme at the home incorporates the Skills for Care Common Induction Standards into the new format. It is recommended that in addition to the safety procedures already being followed in relation to water safety, the home should obtain the Health and Safety Executive booklet on the prevention of legionella in care homes. 2. OP15 3. OP18 4. 5. 6. OP29 OP30 OP38 Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 24 Royal Cambridge Home DS0000013775.V347092.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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