Inspection on 21/05/07 for Foxmead

This inspection was carried out on 21st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Foxmead 20/05/08

Foxmead 30/05/06

Foxmead 29/09/05

Foxmead 08/04/05

Foxmead 12/10/04

Foxmead 12/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Foxmead Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX Lead Inspector Joseph Croft Unannounced Inspection 21st May 2007 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Foxmead DS0000013645.V338790.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. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxmead Address Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX 01306 888053 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) Mrs Evelyn Ramdass Mrs Aisah Talip Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14) Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: Over 65 years of age 30th May 2006 Date of last inspection Brief Description of the Service: Foxmead is a Victorian property situated four miles south of the town of Dorking. It overlooks a church, and used to be the vicarage. The home provides accommodation and care for up to fourteen older people who have a past or present mental illness and/or dementia. The home has been extended and has ten single and two double bedrooms on the ground and first floor. None of the bedrooms are en-suite, however, all have a washbasin and toilet and bathing facilities are located close to all bedrooms. The first floor can be reached by the main staircase which has a chair lift fitted, however there is a break in the chair lift track on the landing between the ground and first floor. There is no shaft lift fitted. There are two large lounges and a dining room, which overlook the garden. The garden is large and well maintained and has wheelchair access via a ramp. There is ample parking to the front of the property and a regular bus service to Dorking, which stops outside the home. The weekly fees range from £500 to £600. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 21st May 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and he was assisted throughout the site visit by the manager and Responsible Individual who was representing the establishment. This site visit took place over a period of six hours, commencing at 12:00 and concluding at 19:45. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. During this site visit the Inspector had discussions with members of staff on duty, and four residents. Residents were observed to be appropriately cared for, with staff attending to and supporting individuals as and when required. Staff spoken to were complimentary about the manager of the home. Residents were limited in their response to questions asked, however, they were able to convey to the Inspector that they are very happy living at the home, that the staff are very nice, and that they thought the food is good. Staff were addressing residents by their preferred names. The pre-inspection questionnaire completed by the home and comment cards received from residents, their relatives and other associated professionals have been used as a source of evidence in this report. The inspector would like to thank the members of staff and residents for their cooperation during this visit. Feedback was provided to the manager and Responsible Individual at the end of this site visit. What the service does well: Assessment documentation is in place to ensure the individual needs of residents can be met. People who use the service are protected by the home’s recording of medication procedures. Physical and health care are offered in such a way as to promote residents’ privacy and dignity. Residents’ lifestyles match their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 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 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. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: Two care files were sampled as part of the case tracking process. These contained pre-admission assessments that had been undertaken prior to residents moving into the home, one from the care manager, and one that was undertaken by the manager at the resident’s current placement. The manager stated that all prospective residents and/or their relatives visit the home before they decide to move in. The home has an Admission and Referral policy and procedure that is followed when referrals are made to the home, however, the manager has been advised to review this document to include that residents are to be encouraged to visit the home prior to admission. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 9 The manager informed the Inspector that the home does not offer intermediate care. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s recording of medication procedures. Physical and health care are offered in such a way as to promote residents’ privacy and dignity. EVIDENCE: Care files sampled contained care plans that had been reviewed on a monthly basis. Care plans included information in regard to residents’ personal and health care needs, physical and mental health, religion, ethnicity, and dietary needs. Care plans detailed how residents preferred to be supported with their personal care. It was noted that care plans had not been signed by residents and/or their representative. Discussions took place with the manager and Registered Individual in regard to this. A good practice recommendation has been made that reasons as to why care plans have not been signed by the resident should be recorded. Evidence was viewed that statutory reviews had been undertaken. Care files of residents sampled included a risk assessment in regard to falls and manual handling. However, other risk assessments must be produced to minimise the risk of identified hazards. A requirement has been made in regard to this. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 11 Health care needs had been recorded in care plans, and records of appointments are maintained in the diary and daily notes. Residents are registered with the GP, Dentist, Optician, and Chiropodist. Records of nutrition and monthly weights were observed in the care files sampled. The manager informed the Inspector that no resident living at the home has pressure sores, however, staff have received training in regard to tissue viability. Residents spoken to informed the Inspector that they see the GP when they need to, and attend dentist and optical appointments. The pre-inspection questionnaire informed that the home has a policy and procedure in regard to the administration of medicines. This had been reviewed on the 1st April 2007. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for residents who were part of the case tracking process were accurately maintained. The home has one resident who is currently taking a prescribed controlled drug. Records of this are appropriately maintained in a controlled drug register, signed by two members of staff, and stored in a secure locked metal cabinet. The manager informed the Inspector that no resident is capable of self-administering his or her medication. The pre-inspection questionnaire informs that staff have attended training in regard to the administering of medication. The local pharmacist undertakes an annual audit of the home’s medication. During discussions staff informed the Inspector that they respect residents’ privacy and dignity at all times through knocking on bedroom doors, calling residents by their preferred names and attending to personal care needs in the privacy of their bedrooms. Residents have access to a telephone in the home, however, most residents require support when receiving telephone calls. Staff stated that residents receive their own mail, and wear their own choice of clothing. Comment cards received from relatives were all complimentary about the standard of care provided at the home, the staff and the manager. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles match their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a healthy balanced diet. EVIDENCE: During the site visit residents were observed to be taking part in a general knowledge quiz. Staff informed the Inspector that activities are provided in the morning and afternoon for residents to take part in if they wish to. The home has an activity list that is displayed where residents can read it. Activities offered to residents include word games, crosswords, ball games, exercise with music and board games. Residents’ interests and hobbies are recorded in their care files. The manager informed the Inspector that the religion of all but one resident is Church of England, and all residents attend the local church every Sunday. This provides them with the opportunity to continue supporting their faith and to meet other people outside of the home. One resident is a Roman Catholic, and receives weekly Holy Communion from a religious representative of that faith. All residents are that of White British origin. Staff stated that racial, religious and cultural needs of any resident living at the home would be respected and promoted. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 13 There are no restrictions to visitors at the home, and residents are able to meet with their relatives in the privacy of their bedrooms, or go out for the day with them. Residents who were able to converse with the Inspector stated that they have visits from their relatives and friends. Residents are able to choose what they do, activities they wish to take part in, and the food they like to eat. The home uses a three-week rolling menu that was submitted with the preinspection questionnaire. Meals include meat, pasta, fish, fresh fruit and vegetables. Lunch was observed during this site visit. Residents were enjoying their meal, which was a relaxed and unhurried occasion. There were sufficient staff available to offer support as and when required. The home is currently in the process of recruiting a cook. Staff were covering cooking duties, and evidence of training in regard to food hygiene was observed in staff training files sampled. Food was appropriately stored and daily records of fridge/freezer temperatures were observed. Comment cards returned from residents informed that all residents like the meals provided at the home. This was confirmed during discussions with some residents during the site visit. The home had an inspection by the Environmental Health Office in December 2006. The manager stated that no recommendations were made during this visit. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protects residents, however, the policy and procedure requires reviewing. EVIDENCE: The home has a Complaints Policy and Procedure that is displayed in the home. This document includes the timescale for responding to complainants and the Commission For Social Care Inspection contact details. All comment cards returned by residents and relatives informed that they knew who to make a complaint to, however, they have not had the need to make a complaint. Residents spoken to stated they would talk to the staff or manager if they were unhappy. The home has a complaints book that was viewed. No complaints had been received during the last twelve months. The pre-inspection questionnaire informed that the home has a Protection of Vulnerable Adults Policy and Procedure that was reviewed in 2007. The home has an up to date copy of the Surrey Multi-Agency Protection of Vulnerable Adults Procedures. Discussions took place with the manager in regard to the content of the home’s Protection of Vulnerable Adults policy and procedure, as it does not provide sufficient detail in regard to what is abuse, or full guidance on the procedures that are to be followed. A requirement has been made that the Protection of Vulnerable Adults policy and procedure must be reviewed to ensure it is written in line with the Surrey Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 15 Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. Staff were able to give an account of who to report suspicions of, or actual, abuse to in the home, and stated they would report bad practice to the manager. Evidence that staff had attended training in regard to the Protection of Adults was viewed. The manager informed the Inspector that three new staff are to attend this training on the 31st July 2007. The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the care home. Foxmead DS0000013645.V338790.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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are provided with clean and tidy communal and individual living space, however, identified areas require attention to ensure it continues to be a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. Accommodation is situated on two floors. The ground floor consists of one double bedroom that is currently unoccupied, lounge, common room with library books, dining room, laundry and kitchen. The first floor accommodates bedrooms, bathrooms and toilets. Bedrooms sampled were appropriately furnished and nicely decorated. Residents had their own personal possessions and lockable facilities. It was observed that two bedrooms require attention. Bedroom number four, which is currently unoccupied, requires attention to the sink unit, as the side panel edge had begun to warp. The radiator cover requires attention to the paintwork, and there was a malodour in the room. The manager informed the Inspector that these would be attended to before a resident occupies this Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 17 room. Bedroom number five requires attention to the cord on one of the windows. The pink bathroom has a new walk in bath with Jacuzzi facilities for residents to enjoy. The home has a portable hoist that can be used in either bathrooms. The décor in the staff room requires attention, and the dining room doorframe needs to be repaired. The home has a large garden to the rear of the property that is used by residents during the warmer months. However, it was noted that some of the flagstones on the patio area have become loose. There is a tennis court to the rear of the garden. The surface had become overgrown with weeds and requires attention. The Registered Individual has begun to re-decorate the internal part of the home, however, the requirement made at the last inspection in regard to the outside of the home has not been met. This requirement will be carried over. A requirement in regard to these issues has been made. All communal areas are accessible to residents. The home has a laundry that has a washing machine with a sluicing facility. This was a requirement made at the previous inspection. Training files sampled during the site visit provided evidence that staff had attended training in regard to Infection Control. On the day of the site visit the home was clean and tidy. Comment cards received informed that the home is always fresh and clean. Foxmead DS0000013645.V338790.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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team support residents to ensure their needs are met. Residents are not supported and protected by the home’s recruitment policy and procedures. EVIDENCE: The staff team is made up of male and female staff. The duty rota was viewed and evidenced there are a minimum of three staff on each shift, and two waking night staff for the nine residents living at the home. Staff are currently undertaking the cooking and domestic duties. The requirement made at the last inspection in regard to staffing levels to be increased at weekends and days when cooking and cleaning duties are undertaken by the care staff has not been fully complied with. The manager informed the Inspector that the Registered Individual works weekends, however, this person’s name was not included on the duty rota. This requirement will be carried over and must be complied with. The manager informed the Inspector that all care staff are currently undertaking NVQ level 2 and level 3 training, and are expected to complete this by the end of December 2007 or January 2008. Upon completion, the home will exceed the National Minimum Standard in regard to 50 of staff holding the minimum of NVQ level two or above. The pre-inspection questionnaire informed that the home had a Recruitment Policy and Procedure, however, the manager informed the Inspector during the site visit that the home does not have this policy. Therefore the home is not Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 19 following a robust procedure in regard to Regulations 18 and 19. Discussions took place with the manager in regard to the wrong information being provided in the pre-inspection questionnaire. It is strongly recommended that the home produces and follows a robust recruitment policy and procedure to ensure residents’ health, safety and welfare are fully protected. On sampling of staff files it was evident that robust recruitment procedures had not been followed. It was of serious concern to note that in some cases the home was using the Criminal Records Bureau clearances from staffs’ previous employers. These are not transferable, and those staff must not work unsupervised until the home has undertaken the POVA first and Criminal Records Bureau clearances. An immediate requirement has been made in regard to this. It was noted that applicants had not provided a full employment history. A requirement in regard to this has been made. The pre-inspection questionnaire submitted to the Commission For Social Care Inspection informed that staff training during the last twelve months had included Dementia, Protection of Vulnerable Adults, Equality, Diversity and Rights, and Nutrition. The home had a list of training dates for the next twelve months that included refresher training on the above and mandatory training. Foxmead DS0000013645.V338790.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): Standards 31, 33, 35, 36, 37 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, issues in regard to policies and staff recruitment must be addressed to ensure the safety and welfare of the residents are maintained. EVIDENCE: The registered manager informed the Inspector that she had been working at the care home for the last seven years, and was appointed to the position of manager in 2003. The manager stated she has a Masters Degree in Social and Healthcare and completed the Registered Managers Award (RMA) in 2005. Other training undertaken by the manager has included Supervision, Assertiveness, Care Planning in Management, Budgeting and Staff Recruitment. The pre-inspection questionnaire informed of all the Policies and Procedures kept by the home, however, it was noted that one policy had not been written, and others did not have dates of review recorded. The registered manager has Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 21 the responsibility to ensure all information provided is accurate. It is recommended that the manager reviews all the policies and procedures in the home to ensure they are in place, and have dates of reviews recorded. Regulation 37 notifications are being submitted to the Commission For Social Care Inspection. During the examining of accident records it was noted that the home is not notifying the Commission For Social Care Inspection of all events in the care home which adversely affect the well-being or safety of any resident. A requirement in regard to this has been made. The home had sent out surveys to residents, their relatives and other associated professionals in April 2007. Some had been returned and were viewed by the Inspector. The manager informed the Inspector that a summary of the findings would be produced and an action plan to address any issues raised would be written and implemented. The manager stated that residents and their relatives handle their own finances, the home does not have any dealings in regard to this. Evidence was viewed that staff are receiving formal one-to-one recorded supervision with the manager. Sampling of staff training records provided evidence that staff are receiving the mandatory training as required. The manager is currently developing an emergency contingency plan for the home, which was a requirement made in the last report. The pre- inspection questionnaire forwarded to the Commission for Social Care Inspection Surrey Local Office provided evidence that health and safety records are appropriately maintained and up to date. Records sampled during this site visit included fire risk assessments, dated July 2006, and records of fire drills. Fire extinguishers had been serviced in November 2006, and a current employers liability insurance certificate was on display. Control Of Substances Hazardous to Health (COSHH) were appropriately stored in a secure locked cupboard, however, the home did not have a COSHH register or risk assessments for these. A requirement in regard to this has been made. Foxmead DS0000013645.V338790.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 2 Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 13 (4) Requirement Any risks to the health, safety or welfare of residents must be assessed and, so far as possible, eliminated. The Protection of Vulnerable Adults Procedure must be reviewed to ensure it contains the appropriate information, and is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. Identified issues in regard to the environment of the home must be addressed to ensure residents continue to live in a safe and comfortable environment. The outside of the house needs painting and some windows and doors need replacing. This requirement is outstanding from the last inspection and must now be complied with. The malodour in the identified bedroom must be resolved. Staffing levels to be increased at weekends and days when cooking and cleaning duties are DS0000013645.V338790.R01.S.doc Timescale for action 21/06/07 2. OP18 13 (6) 21/06/07 3. OP19 23 (2) (b) (d) 21/07/07 4. OP19 23 21/08/07 5. 5. OP26 OP27 16 (2) (k) 18 21/06/07 21/06/07 Foxmead Version 5.2 Page 24 6. OP29 19 (1) (a) (b) 7. 8. OP29 OP38 19 (1) (b) Sch 2 (6) 13 (3) (b) 9. OP38 37 (1) (e) undertaken by the care staff. This requirement is outstanding from the last inspection and must now be complied with. Staff identified must not work unsupervised in the care home until POVA First and Criminal Records Bureau clearances have been received by the home. This requirement is outstanding from the last inspection and must now be complied with. Staff must provide full employment history in their application forms. A register and risk assessments for all Substances Hazardous to Health (COSHH) must be available in the home to prevent unnecessary risk to the health of residents and staff. All appropriate accidents and incidents must be sent to the Commission For Social Care Inspection. 21/05/07 21/06/07 21/06/07 22/05/07 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 OP3 OP7 OP29 Good Practice Recommendations The Admission and Referral policy and procedure should be reviewed and include that residents are to be encouraged to visit the home prior to admission. The reasons as to why care plans have not been signed by the resident should be recorded. It is strongly recommended that the home produces and follows a robust recruitment policy and procedure to ensure residents’ health, safety and welfare are fully protected. DS0000013645.V338790.R01.S.doc Version 5.2 Page 25 Foxmead 4. OP38 A review of all the Policies and Procedures should be undertaken to ensure they are relevant and up to date to ensure the safety of residents. Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way 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 Foxmead DS0000013645.V338790.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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