Inspection on 04/05/05 for Royal Cambridge Home

This inspection was carried out on 4th May 2005.

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

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

Other inspections for this house

Royal Cambridge Home 18/10/07

Royal Cambridge Home 18/04/06

Royal Cambridge Home 18/10/05

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 Announced 4th May 2005 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Royal Cambridge Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Royal Cambridge Home Address 82-84 Hurst Road East Molesey Surrey KT8 9AH 020 8979 3788 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Cambridge Home for Soldiers Widows Mrs Irma Odette Yarnell Care Home 30 Category(ies) of DE(E) Dementia - over 65 (5) registration, with number OP Old Age (30) of places PD(E) Physical Disability - over 65 (2) SI(E) - Sensory Impairment - over 65 (1) Royal Cambridge Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of the persons to be accommodated will be 65 years and over. 2 - The gender of those accommodated will be Female. 3 - Of the 30 service users accommodated, up to 5 may fall within the category DE(E) Dementia - over 65. 4 - Of the 30 service users accommodated, up to 2 may fall within the category PD(E) Physical Disability - over 65. 5 - Of the 30 service users accommodated, up to 1 may fall within the category SI(E) Sensory Impairment - over 65. Date of last inspection 14th September 2004 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 user’s own chosen lifestyle. Royal Cambridge Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs I. Yarnell (Registered Manager) was present as the representative for the establishment. A tour of the premises took place. The pre-inspection questionnaire and documentation, three care plans, environmental health reports, staff criminal record bureau checks and activity plans and documentation were all inspected. Comment cards were sent to service users and relatives prior to this inspection. A total of twelve service users and eleven relatives returned these cards to the CSCI and a correlation of the comments received is quoted in this report. Three of the nineteen service users were spoken to at length, with a further five service users and six on-duty staff being spoken with during the tour. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: The staff work hard to ensure that service users’ needs are appropriately assessed and that their care is planned to ensure that these needs are met. Service users spoken with expressed their satisfaction with their quality of life at the home, one service user commented: ‘The staff are very kind to me. I think they are to everyone.’ Of the eleven comment cards returned by relatives, all responded that they were always made to feel welcome at the home, that they felt there were always sufficient numbers of staff on duty and that they were satisfied with the care that their relatives receive. All interactions observed between staff and service users demonstrated a close and caring staff team. Royal Cambridge Home Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Royal Cambridge Home Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Royal Cambridge Home Version 1.10 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 standard(s) 1, 2, 3 and 6 The homes statement of purpose and service users’ guide now provide service users and prospective service users with the information they need to make an informed decision about admission to the home. Service users are only admitted to the home following a full needs assessment. The home has yet to provide all service users with a written contract. The home does not offer intermediate care. EVIDENCE: At the last inspection a recommendation was made that all service users be issued with a written contract. This recommendation has yet to be met and is now carried forward to this report. 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 have been very happy since I moved in here. It isn’t difficult to be happy here.’ Royal Cambridge Home Version 1.10 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 standard(s) 7, 8, 9 and 10 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 now in place to ensure the safe administration of medication. EVIDENCE: Care plans inspected 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. 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 relative stated on a returned comment card that: ‘I am delighted with the care my relative gets. Staff could not be more helpful or charming.’ Of the twelve comment cards returned by service users 83 stated that they felt well cared for. All of the services users spoken with during this inspection were complimentary regarding the care they receive at the home with one service user stating that the staff are always ready to help. Royal Cambridge Home Version 1.10 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The recent employment and training of an activities co-ordinator is a positive step towards ensuring that activities provided will meet the preferences, expectations and needs of all service users. EVIDENCE: Of the twelve comment cards returned by service users, 75 felt the home provided suitable activities with 25 answering ‘sometimes’. One service user spoken with stated that she wished there were more organised things to do. Since the previous inspection the home have employed an activities coordinator who took up her position in April and has already attended a training course run by Age Concern on the provision of activities. The activity coordinator has been meeting with each service user on a one to one basis to gather information regarding their previous hobbies and interests. The inspector was advised that once that process has been completed the coordinator will be looking to expand the activity programme and draw up individual weekly plans with each service user. The requirement made at the previous inspection has been partly met and will be fully met when this work is completed and individual social care plans have been developed with each service user. Royal Cambridge Home Version 1.10 Page 11 The inspector congratulates the home on the very positive steps they have taken so far in working towards ensuring that the social care and activity needs of all service users will be met. Royal Cambridge Home Version 1.10 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a simple, clear and accessible complaints procedure which includes timescales for the process. EVIDENCE: Of the twelve comment cards returned by service users, all responded that they knew who to talk to if they were unhappy with their care, as did the three service users spoken with during this inspection. The home has a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. It is recommended that this be placed in an easily accessible place and that all staff are made aware of it’s location and contents. Royal Cambridge Home Version 1.10 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 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. Work has started on the making good of the windows requiring repair. On the day of inspection the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. The gardens are established and well kept. One service user commented on how much she enjoyed the view from her room and going into the gardens in the warmer weather. Royal Cambridge Home Version 1.10 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 Since the last inspection steps have been taken to ensure that required checks have been carried out on all staff at the home but this process has yet to be completed. Positive action is being taken to provide staff with the training they require to do their jobs. EVIDENCE: Staff Criminal Record Bureau (CRB) checks were seen at this inspection. At the previous inspection numerous staff were identified as working without a suitable CRB check being in place. Since then the manager has worked hard to obtain the correct checks. However, during this inspection, nine staff members were identified that still need these to be obtained. The requirement made at the last inspection has been carried forward and an additional requirement made. Since the previous inspection the manager has now commenced her Registered Manager Award (RMA) and National Vocational Award (NVQ) training in care. The inspector was also advised that the three care managers are now undertaking NVQ level three in care plus NVQ assessors training with eight of the sixteen care workers now enrolled on NVQ level two in care. The home has purchased a training module for the staff who are required to carry out formal staff supervision and appraisals. This training module only arrived this week and the inspector was advised that the training is due to start soon. Royal Cambridge Home Version 1.10 Page 15 Developing individual training assessments and profiles for all staff is included in this new system, therefore that part of the requirement made at the previous inspection has been carried forward to this report. Of the twelve comment cards returned by service users, all responded that they felt safe at the home, as did the three service users spoken with during this inspection. Royal Cambridge Home Version 1.10 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36 and 38 The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. Most, but not all, 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: The home carried out a survey of service users, their relatives and visiting health professionals last autumn. However, the resulting report was not available at this inspection and a requirement has been made that this be sent to the CSCI, Eashing Office. Since the previous inspection the home has now installed a computer system for the use of the staff. The home has also purchased a new and comprehensive administration package to cover all areas of the administration and management of the home and includes new forms and systems for staff Royal Cambridge Home Version 1.10 Page 17 recruitment, staff development plus new policies and procedures. There are some policies that the home does not have in place at present. Once the new system has been fully implemented these deficiencies should be rectified. The inspector acknowledges that the manager and staff are working hard to familiarise themselves with the computer system and have not yet been able to implement the new administrative package in it’s entirety. The manager now receives formal supervision on a regular basis. The inspector was advised that staff training in formal supervision is due to commence soon now that a new training module has been purchased. As yet formal supervision has not been introduced for other staff at the home. The requirement made at the previous inspection has therefore been carried forward to this report. The Home had inspections carried out by the local Environmental Health Officer last September and December. Requirements and recommendations were made which have yet to be actioned. Of particular concern are some catering staff not having basic food hygiene training and some home risk assessments not being carried out. Requirements have been made regarding these concerns. Royal Cambridge Home Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 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 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 3 x 1 x 2 Royal Cambridge Home Version 1.10 Page 19 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 12.3 Regulation 16 (2)(m)(n) Requirement Timescale for action 04.09.05 2. 29.1 19(1)(b) Schedule 2 (7)(a) 3. 29.1 19(1)(b) Schedule 2 (7)(a) The home must continue to consult with service users about their social interests, make arrangements for suitable social and community activities and provide facilities for activities in relation to recreation, fitness and training for each service user. The home must ensure that they 04.07.05 obtain an enhanced CRB disclosure for all persons employed at the home in positions where they will have regular contact with service users. (Timescale of 14.11.04 not met) With reference to the staff 20.05.05 identified to the manager. The manager to supply to CSCI, Eashing Office, documentary evidence that CRB checks have been applied for. Where these checks have been applied for but not yet returned, the manager to supply documentary evidence that the manager has contacted CRB to chase their return. Royal Cambridge Home Version 1.10 Page 20 4. 30.4 18(1)(a) (c) 5. 33.4 24(2) 6. 33.9 12(1)(a) (b) 7. 36.1-3 18(2)(a) 8. 38.1 38.4 12(1)(a) (b) 23(5) 12(1)(a) (b) 23(5) 9. 38.1 38.4 10 38.2 18(1)(a) (c) 11 33.10 12(1)(a) The home must develop individual training assessments and profiles for all staff. (Timescales of 07.07.04 and 14.11.04 not met) The home must supply a copy of the report regarding the service user survey carried out last year to the CSCI, Eashing Office. The home must ensure that all policies, procedures and practices are in place and regularly reviewed, in line with current legislation and good practice guidelines. The home must implement formal staff supervision and ensure that staff offering supervision are appropriately trained. (Timescales of 07.07.04 and 14.11.04 not met) The manager to contact the local Environmental Health Officer for advice on actioning their inspection report requirements and recommendations. The requirements and recommendations made by the Environmental Health Officer (EHO) on 19.09.04 and 09.12.04 to be actioned as soon as possible. The manager must 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. The registered person to provide CSCI, Eashing Office, with an action plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. Version 1.10 04.08.05 04.07.05 04.08.05 04.08.05 13.05.05 To be agreed with the local EHO 04.06.05 04.06.05 Royal Cambridge Home Page 21 3. 33.10 12(1)(a) The registered person to provide CSCI, Eashing Office, with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. 04.06.05 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 2.1 2.2 Good Practice Recommendations Brought forward from 14.09.04 It is recommended that the home develop and issue a contract/statement of terms and conditions with each service user that includes all details listed in National Minimum Standard 2.2. It is recommended that the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults be placed in an easily accessible place and that all staff are made aware of it’s location and contents. 2 18.1 Royal Cambridge Home Version 1.10 Page 22 Commission for Social Care Inspection 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 Version 1.10 Page 23 - 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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