Inspection on 25/07/07 for 267 Hersham Road

This inspection was carried out on 25th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

267 Hersham Road 04/05/06

267 Hersham Road 30/11/05

267 Hersham Road 01/08/05

267 Hersham Road 29/11/04

267 Hersham Road 15/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Hersham Road (267) 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ Lead Inspector Vera Bulbeck Unannounced Inspection 25th July 2007 11:15 Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 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 Hersham Road (267) DS0000013470.V338641.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 Adults 18-65. 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. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hersham Road (267) Address 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ 01932 226125 F/P 01932 226125 hersham@regard.co.uk 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) The Regard Partnership Limited To Be Confirmed Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 20-65 years Services users shall all be in the category LD (Adults with learning disabilities). Two named persons may also have a physical disability. 4th May 2006 Date of last inspection Brief Description of the Service: 267 Hersham Road is a care home providing residential care for up to six residents with mild to moderate learning disabilities, two of which may also have a physical disability. The home is detached and is situated in a residential area a short distance from Walton on Thames town centre and its facilities. The bedrooms are situated on two floors, two bedrooms are on the ground floor and four bedrooms are on the first floor. The bedrooms are personalised and homely. There is a bathroom on each floor. Currently there are two male and three female service users living in the home. The garden is of a good size, secluded and safe for the service users to enjoy, however the garden does need attention. There is parking for three cars and the homes vehicle in the front of the building. All the staff need to attend equality and diversity training to ensure all the service users needs are being met. The fees for the home range from £1289.00 to £1450.00. Items not covered by the fee, one service user has not had any holidays built into her package of care, and therefore the funding for holidays has to be paid from her personal allowance. Other items not covered by the fees include additional activities, personal items, clothing and toiletries. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over eight hours and thirty minutes commencing at 11.15 and ending at 19.45pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Two care plans were sampled and the care observed for the two service users. The inspector observed the care provided on the five service users, three service users are able to communicate. Four members of staff were spoken to during the visit and a number of records were observed. A registered manager has not been in post for some considerable time. The current manager has been in post since April 2007 and is in the process of submitting his application of registration. There were five service users living in the home on the day of the site visit and there was one vacancy. The inspector would like to thank the service users and staff for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection? There were a number of requirements made at the previous inspection and all have been met except one. Information taken from the Annual Quality Assurance Assessment (AQAA) states, the home has implemented and reviewed menus with input involving Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 6 the service users and planning the menu. A change in the food-shopping day to allow service users to be more involved with regards to buying food. Each service user has an individual daily activity plan, which includes expressed interests of each service user. Supervision for all staff has been implemented and key worker meetings have been undertaken to ensure that staff views and wishes are sought as well as day to day service provision including activities, holidays etc. The inspector would advise the management of the home to keep up to date with the many changes of the Commission for Social Care inspection and to check on the website on a regular basis. The management of the home also need to ensure a copy of the Care Homes for Younger Adults, National Minimum Standards and the Care Homes Regulations are available in the home to enable staff to use as a working tool. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home are only admitted following a needs assessment to ensure that the home can meet the service users identified needs. The home does not offer intermediate care. EVIDENCE: All service users entering the home have a pre needs assessment carried out to ensure the home can meet the service users needs. The staff on duty explained that full details of any potentially new service user would be undertaken before the service user enters the home. Also when the service user enters the home the manager explained the admission procedures and criteria to reflect the principles of admission and assessment appropriate to the home. The pre assessment document was seen and it was noted that service users are involved in the assessment, prior to admission to the home. The staff on duty informed the inspector that a copy of the service users guide is provided to each individual person. The document is provided to relatives. This document was not checked on this visit, the inspector was informed it is updated on a yearly basis. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 9 The home does not offer intermediate care. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users health, personal and social care needs are set out in an individual plan of care, to demonstrate needs are met in accordance with the homes philosophy. Service users were observed to be treated in a respectful and sensitive manner. EVIDENCE: Two service users care plans were sampled and there was evidence that service users health, personal and social care needs had been identified and assessed. Care notes were detailed to include service users daily routines. Some service users are able to be involved with their care plan, each service users had signed the two care plans sampled by the inspector. The care plans hold all the relevant information, however they are not user friendly to enable staff to use as a working tool. The manager explained that he is in the process of changing the plans to be person centred. An action plan is in place to meet the physical care needs of the service user, to ensure the support, comfort and dignity of the service user is maintained. The care plans are kept in the manager’s office, and staff has access to the Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 11 care plans. Service users care plan should indicate who are unable to hold a key to their bedroom; care plans must be documented to include the reasons for not holding a key. Staff stated that service users are supported to make decisions affecting their lives in a number of ways. Each person has an allocated key worker, who is trained to offer one to one support and who knows the service user well and understands his or her needs. The majority of service users have limited communication and staff has the experience to enable service users to make some decisions and choices. Holidays, menu planning and outings are mainly with staff support and interaction and generally knowing the service users well. Staff advised that information is provided to service users to assist with decision- making and this is in a format to suit their individual needs. Observation by the inspector was staff are respectful to the service users. It was also noted that service users and staff have a good rapport. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. EVIDENCE: Service users are supported to make choices in their everyday lives as far as they are able. Families of service users are consulted and encouraged to be involved in the decision making process. The five service users attend various activities; for example, bowling, shopping, performing arts (music), drop in club (bingo), cinema and most service users enjoy pub lunches. Three service users attend church on Sundays. Staff take service users shopping and for car rides, stopping off at garden centres for tea and cake, and visit other places of interest. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 13 One service user attends the day centre college and another service user is to attend supported learning in September. The five service users will be going on holiday, two service users are going to Disneyland, and another two service users are going to Centre Parc’s, activity park. One service user informed the inspector she is going on holiday to Bournemouth with her mother. The home has its own vehicle for the service users use and a number of staff are able to drive the vehicle. The manager stated he ensures at least one member of staff is able to drive the vehicle on each shift if possible. The evening meal observed was nutritional and well balanced. Service users had a good helping of cauliflower cheese with bacon, boiled potatoes, carrots and salad for their evening meal. The inspector was informed by the member of staff cooking the evening meal, that one service user refuses to eat vegetables, the member of staff had cooked the service user two fried eggs and bacon from the main menu with two slices of bread as requested by the service user. All the service users had been out for lunch on the day of the site visit as the plumber was attending to a leak in the kitchen and the garden tap. Staff informed the inspector that service users are involved with the menu planning. The menu is displayed on the kitchen fridge. Staff supports service users to ensure they eat healthily. Food intake and nutritional content is monitored and all service users are weighed monthly. All members of staff who are undertaking the cooking have undertaken training on food and hygiene and have a certificate. It was noted that a new member of staff had not received this training but was at times undertaking the cooking. The member of staff should not be cooking until he has completed the training. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. Medication needs to be reviewed. EVIDENCE: The inspector was informed by staff that service users are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. There are regular visits to the local G.P and service users have an annual health check. The medical team as well as other professional health care people, including the dentist and optician when required, constantly observe all service users. The management of the home will liaise with support services to ensure appropriate equipment is received when necessary. A number of risk assessments were seen, risk assessments were in place for each service user, and the manager explained the process is updated on a regular basis. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 15 The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. The manager monitors the medication and the MAR sheets. Any recurring gaps or errors would be discussed with the member of staff. Staff stated that the member of staff making the entry, signs any additional entries to the MAR sheet that have been handwritten. Two staff sign the MAR sheet for all medication given and for the receipt of medication into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Only staff that have received medication training are allowed to administer medication. There are no service users who are able to self medicate. One service user goes home on a regular basis, and the staff ensures the service user takes medication home. A bottle has been hand labelled specifically for the service user to take home, and staff place the tablets inside the bottle. This practice is not acceptable and needs to be reviewed and discussed with the doctor. A separate prescription needs to be prescribed for weekend purposes only. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff have received training in protecting vulnerable people and are aware of the procedures and practices, to ensure that service users are safeguarded, as far as reasonably possible, from harm or abuse. However, a number of staff need updates to the training. EVIDENCE: There were two recorded complaints; which had been handled appropriately the manager informed the inspector one complaint is still in process. Records seen indicated that complaints would be responded to within the guidelines. The Commission for Social Care Inspection (CSCI) have not received any direct complaints. There is currently one Safe Guarding Adult investigation on going. The homes complaints procedure for service users is in pictorial form and staff stated that some service users would be able to use it when necessary. The complaints form is written with widget symbols and easy for service users to understand. A copy of the complaints procedure and another form stating “I want to speak up” hangs on the notice board in the hallway of the home. There are two new members of staff who need to attend training on the protection of vulnerable people. The majority of staff has completed the vulnerable adults training. However, a number of staff needs updates to the training. The manager confirmed that staff cover training on induction but need more in depth training for the new members of staff. Some staff spoken to stated they had undertaken training in the protection of vulnerable adults and were aware of the whistle blowing policy. Staff said they Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 17 would be willing and able to report any concerns and “would go to any level to protect service users”. The service users have a bank account and regular statements and receipts were available. The home manages the five service users finances. All service users have an individual bank account. Staff check the records on a daily basis. The finances of two service users were checked by the inspector and found to be correct and the money balanced against the records held. The receipts were available and matched the records. Surrey Multi Agency procedures need to be updated the current procedures are dated 2001. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the home are continuous in order to ensure a safe and wellmaintained environment for service users. Some areas in the home need attention. EVIDENCE: The lounge, dining area and hallway have recently been decorated. Bedrooms were personalised with some items purchased by the service users. However, all the bedrooms need decorating and a number of carpets were badly stained. Service users need to be provided with a cupboard to store toiletries, on the day of the site visit it was noticed that plastic baskets containing toiletries were on the floor or on the window ledge of the bedroom. One service user informed the inspector she has requested her bedroom be decorated. The inspector also noted that this was also requested in the service users meeting notes. There were a few other areas that require attention for example the window frames in the bathroom have mould, this is an on going problem a requirement was made at the previous inspection for the window frames to receive Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 19 attention, and the work was completed. However, the mould had grown once again. The inspector advised the manager to contact a qualified electrician on the suitability and safety of the light in the bathroom. Bathrooms on the ground floor and first floor are in need of decorating. The kitchen needs attending too it is very tired looking, a handle was broken off the freezer and the freezer needs defrosting. The laundry, which is situated in the garden needs attention, the cupboard under the sink containing cleaning materials was unlocked as the lock was broken and the shelf was also broken. There were several tins of paint on the working surface of the laundry, which need to be stored appropriately. A number of fence panels need to be replaced and the rubbish needs to be cleared from the garden, there is an old tumble dryer, which was requested to be removed some considerable time ago, as indicated in the maintenance book. The home has had a number of problems with the drainage/sewage pipe. Dyno Rod have been into the home once again to sort the problem and has suggested that the reason for the blockages is that where the pipes join they overlap and if for example a lot of toilet paper is used this causes the blockage. The home to monitor the problem and if this happens again to consider work on the pipes being fitted properly. The garden is nicely presented and during the good weather service users are able to use the garden. The garden is accessible and clearly the service users enjoy sitting in the garden when the weather permits. However, the garden does need attention. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff recruitment procedure needs to be reviewed as detailed in the previous report. The number of staff on duty was adequate to meet the needs of service users. However, staffing levels need to be regularly reviewed, to ensue the needs of the service users are met at all times. EVIDENCE: The manager stated staffing arrangements are constantly reviewed. At present there are two members of staff on duty for each shift. Another member of staff is on duty between 9am until 5 pm therefore three members of staff are on duty through out the middle of the day. This does not include the manager, however the manager does cover some of the shifts identified on the rota. The staffing arrangements for nighttime are one sleeping in person on duty. There is also a person on call to assist if necessary. Two staff files were inspected and it was noted that staff files were in order and the majority of relevant documents were in place. However, one staff file was without an up to date photograph and another file only had one reference. Training certificates were not kept up to date and some certificates were missing. The inspector was informed that all new staff had completed induction training over a period of one week. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 21 Some staff working in the home has been employed for some considerable time. The management of the home have recently employed a number of new staff. There have been a number of management changes in the home, which has caused some anxiety amongst the staff. There is a need for the staff to work as a team to ensure the needs of the service users are met at all times. Staff informed the inspector that it has been difficult at times covering the shifts, and sometimes there have been staff shortages. Staff training needs to be up dated on a number of courses. A training plan is used. However, the training plan could be more detailed, for example to include the training needs of more specialist training for some staff. The home needs to ensure all staff undertake equality and diversity training, as well as Infection control, food hygiene and the protection of vulnerable people training as a matter of urgency. Staff members spoken to confirm they are aware of the different needs of the service users, and staff work with service users in this area to ensure their needs are being met. Interaction between staff and service users was observed to be good. One member of staff has completed NVQ Level 2 and above, and four members of staff are working towards completing NVQ Level 2 and above. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has been operating without a registered manager for some considerable time. The management of the home to ensure all staff undertake COSHH training to protect and ensure the health and safety of all service users. The majority of service users are able to make their views known. EVIDENCE: The newly appointed manager has been in post for a short time and is in the process of submitting his application for the registered manager position. The manager has completed the Registered Managers Award on 07/04/06 and is experienced and competent to manage the home. Staff confirmed the manager is supportive and has an open door policy. The home has a quality assurance system in place to gain feedback from service users and their families. A quality assurance audit is undertaken on a regular yearly basis. The last survey was undertaken in June 2007 this was for Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 23 the professional persons to complete and service users will be receiving a survey very shortly. The inspector advised the manager to include relatives as well. The monthly monitoring visits by the responsible person were well documented and covered a wide area of care practice in the home. Timescales and action was included. It was good to see the Performa used with regard to a mock Inspection report. The management have identified a number of areas for improvement and an action plan on meeting the standards was in place. A number of records were observed and were well documented. However the home needs to use an accident book that is recommended by the health and safety executive and complies with data protection. The home is currently using loose sheets of paper. The inspector advised the management of the home to have in place a fire risk assessment and an emergency contingency plan, in the event of a fire these records need to be available. An immediate requirement was left at the end of the inspection in relation to cleaning materials being stored in unlocked cupboards. The manager has informed the inspector this work has been undertaken, appropriate locks have been fitted to ensure the health and safety of the service users is maintained at all times. The Commission for Social Care Inspection received: Two surveys were from Health professionals, as a result there were no significant comments to include in this report. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 19(1)(b) Schedule 2 Requirement The registered person must check all staff files and make arrangements to 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 Timescales of 11/01/06, 02/06/06 and 07/11/06 not met. Medication needs to be reviewed and discussed with the doctor. Secondary medicating must not be administered. Bedrooms and bathrooms need to be upgraded and decorated. A number of areas in the home need attention. The garden needs to be cleared of rubbish and new fence panels need fitting.. All staff must have up to Timescale for action 31/08/07 2 YA20 13 17/08/07 3 4 5 6 YA24 YA24 YA24 YA35 23 23 23 18 28/09/07 28/09/07 17/08/07 28/09/07 Page 26 Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 date training. 7 YA42 13 Appropriate locks must be fitted to cupboards containing hazardous substances. 26/07/07 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 2 3 Refer to Standard YA23 YA42 YA42 Good Practice Recommendations The management of the home needs to ensure an up to date copy of Surrey Multi Agency procedures is available in the home. Management of the home to ensure a fire risk assessment, and an emergency contingency plan is in place. To ensure an appropriate accident book is in place. Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 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. Extracts may not be used or reproduced without the express permission of CSCI Hersham Road (267) DS0000013470.V338641.R01.S.doc Version 5.2 Page 28 - 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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