Care Home: Cypress Court Nursing Home

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What the care home does well Cypress Court is a very well run care home and staff who work there are highly regarded. One person commented, "a very nice Nursing Home and I am quite happy here. All the staff are very helpful and cheerful." Care staff levels appear adequate and staff are given training to help them perform their role to a good standard. People considering moving into Cypress Court have their needs assessed before admission so they know their needs can be met. Medication is well managed so people receive their medication in a safe manner and as prescribed. The home provides residents choice in their daily lives. The standard of catering is good so residents are well nourished and there is a range of activities available that residents can choose to take part in.The home manages complaints well so that people know their concerns are being listened to and appropriate actions taken to answer those concerns. Cypress Court offers a clean, pleasant and well-maintained environment so residents live in safe and comfortable surroundings. What has improved since the last inspection? The manager was successful in becoming registered with the CSCI as required by law. Equipment used in the home was clean as was the environment and no unpleasant odours noticed so that people living in the home are protected from possible infection and live in clean surroundings The home`s recruitment process has improved so that two references are provided for staff and people living in the home know that staff are suitable to work there. Staff undergo an induction process which can last from three to six months and according to their ability so that they are confident to work in the home. What the care home could do better: Any risks relating to the care of people admitted to the home for intermediate care should be recorded and monitored so that these risks can be well managed. Records about the prevention and management of pressure ulcers need to be improved so the home can demonstrate that it is providing effective care. Menus should be displayed in dining rooms so people know what the choices are at meal times. All staff should undertake training in safeguarding adults so they known what to do if they suspect someone is being abused. Improvements are needed in the garden area so that residents can enjoy sitting outside. Adequate provision should be made to cover for staff shortages in the laundry so the home can provide an effective service. Training records should be kept up to date as evidence that staff have completed all mandatory training. CARE HOMES FOR OLDER PEOPLE Cypress Court Nursing Home Broad Street Crewe Cheshire CW1 3DH Lead Inspector June Shimmin Key Unannounced Inspection 19th August 2008 09:20 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 Cypress Court Nursing Home DS0000018723.V364985.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. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cypress Court Nursing Home Address Broad Street Crewe Cheshire CW1 3DH 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) 01270 588227 01270 211887 cypress.court@schealthcare.co.uk Southern Cross Healthcare (Cheshire) Limited Mr Gerard Hill Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 60 service users to include: * Up to 60 service users in the category of OP (old age not falling within any other category). Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th September 2006 2. 3. Date of last inspection Brief Description of the Service: Cypress Court Care Home is a purpose built, two storey, detached property located in a residential area close to Crewe town centre. It has good access to local amenities and services, including public transport. The home provides personal and nursing care and accommodation for up to 60 people over 65 years of age. Bedrooms are on two floors with a passenger lift and staircases providing access to the first floor. There are 56 single rooms and two double rooms, all of which have en suite toilet facilities. There are two lounges and a dining room on the ground floor, and on the first floor there is a combined lounge and dining room, and another separate dining room. There is also a small garden with patio area to the rear of the property. Current fees range between £367.54 and £522.66 depending on the type of care being provided. Further charges apply for toiletries, chiropody, hairdressing, newspapers etc. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. An unannounced visit was carried out on 19 August 2008 by one inspector and lasted nearly nine hours. An expert by experience also visited the home as part of the key inspection. An expert by experience is a person who, because of their shared experience of using services and/or ways of communicating visits a service with an inspector to help get a picture of what it is like to live in or use the service. This visit was just one part of the inspection. Other information received about the home was also looked at. Before the visit the home manager was asked to complete a questionnaire to provide up to date information about Cypress Court. CSCI questionnaires were also sent out to people who live in the home, their families and staff in order to find out their views. Other information since the last key inspection was also reviewed. During the visit, various records and the premises were looked at. A number of people who live at the home, several relatives and staff were spoken with and they gave their views about Cypress Court. What the service does well: Cypress Court is a very well run care home and staff who work there are highly regarded. One person commented, “a very nice Nursing Home and I am quite happy here. All the staff are very helpful and cheerful.” Care staff levels appear adequate and staff are given training to help them perform their role to a good standard. People considering moving into Cypress Court have their needs assessed before admission so they know their needs can be met. Medication is well managed so people receive their medication in a safe manner and as prescribed. The home provides residents choice in their daily lives. The standard of catering is good so residents are well nourished and there is a range of activities available that residents can choose to take part in. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 6 The home manages complaints well so that people know their concerns are being listened to and appropriate actions taken to answer those concerns. Cypress Court offers a clean, pleasant and well-maintained environment so residents live in safe and comfortable surroundings. What has improved since the last inspection? What they could do better: Any risks relating to the care of people admitted to the home for intermediate care should be recorded and monitored so that these risks can be well managed. Records about the prevention and management of pressure ulcers need to be improved so the home can demonstrate that it is providing effective care. Menus should be displayed in dining rooms so people know what the choices are at meal times. All staff should undertake training in safeguarding adults so they known what to do if they suspect someone is being abused. Improvements are needed in the garden area so that residents can enjoy sitting outside. Adequate provision should be made to cover for staff shortages in the laundry so the home can provide an effective service. Training records should be kept up to date as evidence that staff have completed all mandatory training. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cypress Court Nursing Home DS0000018723.V364985.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 Cypress Court Nursing Home DS0000018723.V364985.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their needs assessed before admission so they know the home will be able to meet their needs. EVIDENCE: The inspector spoke to several people about their admission to Cypress Court care home. One person said, “all the necessary information was given about Cypress Court and I consider it a very satisfactory home” and another said that her daughters had come to look around the home in the first instance. The assessments of three people recently admitted to the home were seen. The manager, who is a first level registered nurse, had carried out the assessments. The content of the assessments was of a good standard and Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 10 included an assessment of any risks to the person’s health. One assessment was for a person admitted to Cypress Court for a short period of rehabilitation prior to going back to their own home. In two instances there was little recorded about the social, leisure and spiritual interests of the people admitted to Cypress Court and in the third case the information was non-specific. For instance the assessment said that the person enjoyed television but not which programmes. However, this information was recorded in more detail on admission to the home. This information is important as it enables carers to understand the unique cultural and life history of the individual, and as a consequence staff can deliver person centred care. The person admitted for intermediate care had been in the home for just over a week. Although the person was in control of some medication care staff kept the self-administration container so that the person was not yet being encouraged to manage their own medication and to become independent. Likewise the person had not yet been supported to make a drink but was going on a home visit the following day. The person was able to show the inspector a book that the manager had given her showing a photograph of the house where she used to live, which is a good example of person centred care. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people living in the home are mainly met and care is provided in a manner that protects their privacy and dignity. EVIDENCE: The care plans of five people living in the home were seen. The person receiving intermediate care did not have a care plan as the person’s social worker had completed an assessment with a list of agreed actions to be taken by care home staff. It is advisable to complete a short care plan that as a minimum describes any risks and the actions to be taken by care home staff to manage those risks. All except one of the other four care plans were written on the day of admission so that any care needs and risks were quickly identified and actions recorded to meet those needs. The care plans identified most relevant care needs and risks. The content of three care plans was good Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 12 and made reference to people’s preferences and choices. The fourth care plan lacked detail about the prevention and management of a number of pressure ulcers and did not include care plans for all identified needs. The care plans mainly demonstrated that staff had taken the principles of privacy and dignity into account so that staff would be aware of the importance of maintaining each person’s privacy and dignity. The care plans had been reviewed on a monthly basis although one person’s first review was slightly overdue. This means that care staff evaluate whether care is effective and make any amendments to the care plan that may be necessary. It was noted that in several cases the home was using two tools to assess whether the individual was at risk of developing pressure ulcers. Unfortunately, the outcome of these two tools gave different results so that it might be difficult for care staff to identify if the person was at risk and take appropriate actions. The manager said that where possible, residents are encouraged to take part in drawing up their own care plan so they know what care will be provided and agree to the actions being taken. A visitor confirmed that she was involved in the care planning and review process on behalf of her relative. Records indicated that the home seeks advice from a number of health care professionals in the management of care needs of people living in the home. These professionals included GP’s, optician, district nurses and dietician amongst others. Medication records were also of a good standard so that people receive their medication safely and as prescribed. Interactions between staff and residents were friendly, humorous and sensitive so people felt they were treated with respect. Care plans indicated the individual’s preferred name so that they were addressed in an appropriate manner. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home appear well nourished. A range of activities are provided which people can choose to take part in thereby offering them a degree of stimulation and social interaction. EVIDENCE: Cypress Court employs a person to provide activities in the home. She works five hours a day over four days but works flexibly to meet the needs of the home. An activity programme for the current and following week was displayed in the entrance to the home and written in large print to make it easier for people to read. Although the advertised activities related mainly to group activities the activity coordinator takes time to sit and chat to people in small groups or to individuals who prefer to stay in their room. Several people said that they had enjoyed a recent Irish evening and the activity coordinator said that she was hoping to organise further social events with a food theme. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 14 The food provided at Cypress Court appeared nutritious. One person said that there was no choice for the evening meal but there was a choice on the day of the inspection of hot and cold food and choice of dessert. One person commented, “the food is very good, they come and ask what you want.” Another person would have liked more variety and someone said they did not like the bread used for toast and sandwiches. There only appeared to be white bread available. The expert by experience noted, “a number of old photographs decorating the walls of the reception area and also a large display of photographs taken at various events held for residents. The menu for the current week and the following week was displayed in the foyer of the home. However, there was no menu available in the ground floor dining room. Tea/coffee making facilities and a microwave oven were available to visitors to make drinks for themselves or relatives. On the first floor, the dining room was attractively set out and well furnished.” On the first floor the expert by experience made the following comment, “the lounge area is spacious and one end has a large “cinema” style television screen. There is an extremely well stocked library with books, DVDs and video.” “Holy Communion was available on the last Thursday of each month when a lady called to hold a service. This lady was readily available should any resident wish to take communion more regularly or express a wish to see her.” The expert by experience joined with a group of residents for lunch and enjoyed his meal. He wrote, “I had been told that lunch was served at 12 noon but it was almost 12.25pm before service began. This caused some disquiet among the residents. There was a choice of meal, the portions given were generous and the food was hot. The residents appeared to enjoy the lunch; those who required assistance were helped with patience and understanding. People were given adequate time to consume the lunch.” Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cypress Court provides effective policies and procedures about complaints and safeguarding adults but needs to ensure that all staff undertake training in safeguarding adults so that people living in the home are protected. EVIDENCE: The home has a complaints policy and procedure and people living in the home and relatives were aware of what they should do if they had any concerns. The complaints procedure included contact details of the CSCI so people would know how to contact us if they wished. The procedure was displayed at the entrance of the home where it could be seen. The manager had kept a record of complaints made to the home, together with details of any investigations and the actions taken as a result of the complaints. The manager had policies and procedures relating to safeguarding adults and these included the latest update of the “No Secrets” policy, which is a national policy about safeguarding. Although the manager said that a number of staff had undertaken training in this subject he could not confirm exact numbers as the training matrix was not up to date and records of staff training were waiting to be filed. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, pleasant and well-maintained environment. EVIDENCE: On arrival the home was clean, tidy and no unpleasant odours were noted. Later in the day during a walk around the ground floor this situation was unchanged. The manager said that various improvements have been made to the internal environment of the home since the last key inspection. These included new carpets to a number of bedrooms, the foyer and a lounge and redecoration of these areas. The home has also purchased a large number of easy chairs and Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 17 several specialist beds for people with disabilities or at risk of developing pressure ulcers. Externally the home is in the process of building a remembrance garden but many areas of the gardens were overgrown with weeds. This issue was outstanding from the previous key inspection. The manager said that the home employs a maintenance man but it appeared that his main job gave him little time to attend to the gardens. The expert by experience walked around the building and found the reception area “light, airy and well furnished with comfortable seating.” He also commented on the “excellent state of decoration and size of the rooms. All bedrooms have en suite facilities. Residents are encouraged to bring in small items of furniture and treasured photographs and ornaments.” On the ground floor the expert by experience commented, “The large lounge is split into 2 areas; one containing a large screen television which was on but not at an intrusive level. Although there was a further television at the other end of the lounge a carer said that this area was kept for those who wished to talk with relatives or simply be in a “quiet” place.” Externally, “Although the garden area was quite attractive and well furnished the beds and paths were somewhat overgrown with weeds.” The home has procedures in place to control the spread of any infection in the home. However, it was noted that the laundry was struggling to meet demand. The manager said the laundry staff worked until 4pm but at 5pm the laundry was full of wet washing waiting to be dried and unwashed clothes waiting to be washed. The manager said that one drier was out of action and two staff were currently unable to work so that it was difficult to run this service as efficiently as expected. Many of the name tags of people’s clothing were fading and a box of unclaimed clothes was seen in the foyer of the home so some clothing could not be fully identified. The manager said that a new bag system was being introduced for the residents’ laundry, which should improve this situation. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cypress Court ensures that staff are thoroughly checked before starting work in the home and employs sufficient numbers of suitably trained staff so people living in the home know they will be well cared for. EVIDENCE: Staffing levels at Cypress Court appeared to be adequate. There are two registered nurses on duty at all times, and there appear to be sufficient numbers of care staff to meet the needs of people living in the home. Staff working at Cypress Court are well regarded by people living in the home. One person said, “all staff are very helpful – no complaints whatsoever.” Staff enjoy working at the home, “it’s really nice. I love it, really rewarding.” According to the training matrix twelve care staff have attained NVQ 2 in care, which is virtually 50 of all care staff working in the home and therefore meeting the national minimum standard. The manager said that three care staff have achieved NVQ 3 in care and other staff are working towards the NVQ 2 and 3 awards. Evidence was seen of the certificates of two staff. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 19 Staff files relating to the last two staff recruited were inspected. Each file contained a completed application form, satisfactory references, a health declaration and a POVA first check. This is a preliminary security check from the Criminal Records Bureau (CRB) and demonstrates that staff are suitable to work with vulnerable people. The manager said the full security check from the CRB had not yet been received for either staff member and that both staff members were working under supervision until they arrived. The manager said that the home’s induction programme is linked to Skills for Care, which is the nationally recognised training programme for care staff. One staff member said that she had received initial induction training over a period of three days and was assigned a more experienced staff member to support her. The manager provided written evidence of the induction of another staff member and this record was signed and dated by the staff member and the supervisor. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cypress Court is well managed so that people living there can be confident that the home is run in their best interests. EVIDENCE: The manager has been in post for two and a half years. Since the last key inspection he has been interviewed by the CSCI and is now the registered manager of the home. He is a first level registered general nurse with many years experience in the Army and a Member of the Institute of Leadership and Management. He has started the NVQ 4 award in management and expects to Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 21 complete this by the end of September 2008. He is well regarded by staff and people living in the home. The manager assesses whether the home is providing a good service in a variety of ways. He carries out regular audits of how the home is performing in areas such as complaints and medication and takes any necessary action to put matters right. A senior representative of Southern Cross visits the home monthly and provides a report about how the home is being run. The manager also holds meetings for staff to ask their views about how the home is managed. Meetings are held for relatives but the manager said that there is poor attendance at these meetings. The home also sends out questionnaires on a regular basis to people living in the home and their relatives to find out what they think about Cypress Court. The home has satisfactory procedures in place for the safekeeping of small amounts of money kept by Cypress Court on behalf of residents so they know their money is protected and being safely managed. The manager informed us before the inspection about whether equipment and installations at the home were being serviced on a regular basis. The records of the servicing of fire equipment were seen and this had been carried out in the last year. Fire training records were seen but as the training matrix was not up to date it was difficult to verify if all staff had undertaken this training without going through the individual file of each staff member. The file of one staff member was looked at and the person had done fire training even though it was not recorded on the matrix. Similarly the training records for moving and handling indicated that some staff had not done this training since April 2007. The manager said that two senior staff members were now trained to act as moving and handling instructors and dates had been set in September and October 2008 to make sure that all staff were fully up to date and safe to move residents. Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 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 X 3 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP6 Good Practice Recommendations A short care plan should be provided for people admitted for intermediate care, which includes any identified risks so that staff can demonstrate that they are taking appropriate actions to manage those risks. Records about the prevention and management of pressure ulcers should be improved so they identify the actions needed to provide effective care. The home should only use one tool for the prevention of pressure sores to ensure that there is clarity about whether the person is at risk and so that effective care can be provided. The manager should ensure that menus are displayed in the dining areas in a format that can be seen and understood by people living in the home so that they know DS0000018723.V364985.R01.S.doc Version 5.2 Page 24 2. OP8 3. OP8 4. OP15 Cypress Court Nursing Home what the choice of meal is. 5. OP18 The manager should ensure that all staff have received up to date in safeguarding adults procedures and that a record of this is kept on a training matrix so they home can demonstrate that all staff are fully aware of their role and responsibilities. The gardens surrounding the home should be weeded. The manager should ensure that provision is made to cover for staff sickness so that the laundry is effectively managed. The staff training matrix should be updated and maintained to provide evidence that staff have undertaken mandatory and other training. 6. 7. OP19 OP26 8. OP30 Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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. Extracts may not be used or reproduced without the express permission of CSCI Cypress Court Nursing Home DS0000018723.V364985.R01.S.doc Version 5.2 Page 26 - 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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