Inspection on 12/03/09 for Hamilton House Care Centre

This inspection was carried out on 12th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hamilton House Care Centre 02/12/09

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Hamilton House Care Centre Drayton Lane Drayton Portsmouth Hampshire PO6 1HG Lead Inspector Anita Tengnah Unannounced Inspection 09:15 12 March 2009 th 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 Hamilton House Care Centre DS0000072741.V374379.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. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hamilton House Care Centre Address Drayton Lane Drayton Portsmouth Hampshire PO6 1HG 02392 385448 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) www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Ltd Mrs Linda Murray Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 60. Date of last inspection New service Brief Description of the Service: Hamilton Care Centre is a purpose built care home within a residential area of Drayton. The service was registered with the Commission for Social Care inspection in October 2008. The service is registered to provide nursing and care for up to 60 service users in the older person category and dementia. Accommodation is provided over 3 floors within single occupancy en-suite rooms. Décor and signage has been provided in line with current best practice guidelines for dementia care. Each floor provides ample space, with wide corridors and doors and themed pictures creating a different personality to each. Access between floors is via a passenger lift or stairs. Outside garden areas are accessible via a level path around the rear of the property, secured by locked or keypad access. The outside area is limited to a patio area with a raised flowerbed providing additional seating. Some car parking facilities are available to the front of the home. The current fee charged is £800-£950. Hamilton House Care Centre DS0000072741.V374379.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 1 star. This means that the people who use this service experience Adequate quality outcomes An unannounced visit to the service was undertaken as part of the inspection on the 12th of March 2009. This was the first inspection of the service following its registration with the Commission in October 2008.The process included walking round the service where a number of the bedrooms, communal areas, kitchen, laundry and bathrooms were viewed. As part of case tracking the staff and service users views were sought and care records were looked at. We sent out our Annual Quality Assurance Assessment (AQAA) to the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This is included in this report, as was information gathered by the Commission since the last inspection to contribute in assessing judgements in this report. We also sent out questionnaires to the service users and the staff. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 7 comment cards from the service users and some contained input from their relatives. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: The home has a detailed pre admission assessment process in place in looking at the needs of both potential and existing service users to ensure that the home can meet their needs. The meals at the service are very well managed and offered the service users variety and choices taking into account individual likes and dislikes. There is an activity programme in place that was interactive and met with the satisfaction of the service users. The service users are provided with warm, homely, clean accommodation and maintained to a very high standard throughout. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 6 The management system and procedures in the home worked well offering support to the staff. There is a range of equipment in place to support and maintain the service users’ independence. People we have spoken with and comments received indicated that they experience a high degree of satisfaction with the care that they are receiving. 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. Hamilton House Care Centre DS0000072741.V374379.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 Hamilton House Care Centre DS0000072741.V374379.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment process is good and ensures that service users’ needs are assessed and the home can meet them. The home does not provide intermediate care. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their initial care plans on admission. Assessments of needs included past medical history, dietary needs, social history, manual handling assessments, skin integrity and their hobbies/ likes and dislikes. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 9 The record seen also contained a short care plan from the information gathered at pre assessments prior to more detailed care plans being developed. The manager reported that the service users are offered the choice of visiting the home prior to admission. The service users’ family visited, as most of them were unable to do so due to their frailty. There was detailed information available in entrance hall that relatives/ visitors can access such as the statement of purpose and the service user’s guide. Comments from service users regarding the pre admission information that they received were positive. One comment was that ‘ Face to face meeting with the manager which was very comprehensive’. The manager confirmed that the service does not provide intermediate care. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and records of care given were in place. However risk assessments and care plans in relation to dietary needs were inadequate to safeguard people and must be addressed. The health care needs and access to external agencies are well managed. The medication management was generally satisfactory. However this is not currently managed safely at all times to ensure that people receive their medication as prescribed. The service users are treated with respect and dignity and their right to privacy maintained. EVIDENCE: Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 11 We looked at the care records of two service users as part of this visit to assess how the service was planning to meet the needs of people accommodated. The care plans contained information and assessments such as manual handling, fall assessments, dependency, diet needs, psychological needs. Care plans including night care were put in place to demonstrate how these needs would be met. Daily records were maintained of the care given. Pressure area risk assessments were completed and appropriate equipment was in place. The staff practices that we observed showed that they were aware of the person’s needs when assisting with transferring the service users such as using the hoist and the type/ colour of slings required. We looked at the care records of a service user who was receiving their feeds through a Percutaneous Endoscopic Gastrostomy (PEG) tube. The record for this person did not have detail of the feed regime to ensure that this is administered safely and meet this person’s needs. The record of feed seen in the care plan differed from the feed administered at the time of the visit. There was no swallowing assessment and instruction of the regime, or details of volume to be administered for the PEG feed as instructed from the dietician as required. There was no record of amount of feed given such as a fluid/ food balance record. Other information lacking was details volume of fluid needed to flush the line following each medication administration. These were brought to the attention of the manager and immediate action was required. The nurse in charge contacted the dietician who sent a PEG feed regime for the service user that included details of the type of feed, volume, and flushes required following administration of medication. Care plans must now be developed and put in place to ensure that care is delivered safely. There were other service users who were at risk of choking/ aspiration and they were receiving thickened fluids. One of the service users records showed that a swallowing assessment had been completed in January 09 and this person was prescribed a thickened fluid grade 2 and a pureed diet. The care plan informing the delivery of care did not describe how this would be managed, as it was not available at the time of the visit. The assessments were not available for the other service users receiving thickened fluids. Care plans and assessments need to be developed for all these service users to ensure that they are not put at unnecessary risks and care is provided safely. The care plans should contain details of consistency of the fluids according to their assessments such as amount to be added to food Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 12 and fluids as appropriate. This information should be made available to the staff at the point of providing care. All the service users are registered with the local surgery. The manager reported that the home had good relationships with the local primary care trust and the service users were supported to access health care services as required. The GP did not undertake regular visits to the home but was available on request. We looked at the medication management at the service. A sample of the Medication Administration Record (MAR) seen at the time of the visit showed that staff maintained a record of medication administered. The registered nurses were responsible for medication management. All medication was stored safely and securely. We observed the lunchtime medication round and staff followed good practice guidance while administering medication. A record of the drug fridge temperature was maintained, staff should ensure that both minimum and maximum temperatures are recorded. There were detailed records of all medication that were discarded/ discontinued. A random check of some medication showed that these did not correlate with the stock, these included Temazepam and painkillers, so it was not possible to verify that people had received their medication as prescribed. We also noted that the staff had not clearly recorded variable dosages in some instances as required. Other areas that were lacking and need to be addressed are recording the amount received when people are admitted mid cycle and two signatures when staff transcribe onto the MAR sheets as these were not available. This minimises the risks of error occurring when transcribing details. Comments from the service users included “the staff know what my father needs.” Another comment was the staff are good and treat you well”. Interaction observed showed that the staff were aware of people’s needs and supported them in a respectful manner. Practices observed and the people we spoke to indicated that there was no restriction to the time that people rise or go to bed. Comments received included: The care that my father receives is excellent’ ‘The staff are always very supportive’. Hamilton House Care Centre DS0000072741.V374379.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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The social and recreational facilities for the service users are very good and well managed. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activity of daily living. The meals are good, offering choices, variety and meeting with the satisfaction of the service users. EVIDENCE: The home has a planned and varied programme of activities for the service users. The home employs an activity coordinator who worked five days a week Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 14 and it was evident from interaction observed and staff practices that this was managed well. We observed the activity coordinator supporting one of the service users arranging some flowers for the dining room table. This was carried out in a relaxed and comfortable manner. Time was spent in one to one support with drinks and reading magazines. It was evident throughout the day that the service users were supervised and staff had developed good relationship with the service users and treated them in a respectful manner. We saw an interactive musical session in the afternoon that people appeared to enjoy. The home has an open visiting policy and it was evident from the record of visitors as kept by the home that there was no restriction on visiting. Comments received and a service user confirmed that they have autonomy to receive their visitors in private. A relative said that they visited regularly and assisted their relative with their meals and felt involved in the care of their relative. The home has a planned menu that is rotated on a regular basis. Comment cards received and the service users spoken with said that the meals were “ very good” and hot and cold drinks were available at all times. Comments included “excellent food” and “good choice “. On the day of the visit one of the service users said that she was having a poached egg for her breakfast. The chef reported that there are two service users who regularly have cooked breakfast as per their choice. The service users are provided with a daily menu and staff supported them in choosing from the menu. There were three choices for the lunchtime meal including vegetarian choices. The chef reported that cakes are baked daily for afternoon tea and supper menu consisted of homemade soups, a baked dish and selection of sandwiches. The chef also visited the service users on admission and discussed the meals with them. We observed the lunchtime meal that the chef served in the dining room. It was evident that the chef was well aware of the service users likes and dislikes and a variety of desserts were prepared according to people’s needs. The chef monitored what the service users had eaten and records were maintained of meals served. Lunchtime meal observed appeared well presented, nourishing and balanced. Staff were available to offer support with meals as needed. We spoke to one of the service users who reported that she had requested to take her meal in her bedroom. She commented “the staff are marvellous and it is not a problem”. There is a small kitchen area attached to the dining room on each floor where staff had the facility of preparing hot and cold drinks. Hamilton House Care Centre DS0000072741.V374379.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints management process is good and the service users are confident that their complaints will be listened to. Staff have a clear understanding of adult protection and ongoing training ensures that the service users are protected EVIDENCE: We looked at the complaint procedure and found that this was available in the service users’ guide and was also displayed in the entrance hall. This contained clear details about raising concerns. The manager reported that this is made available to all the service users on admission. The manager maintained a log of complaint received and reported that there has been no concern received. The home also maintained a compliment record and two were seen that praised the staff for their kindness and care. Training in safeguarding is available to the staff and discussion with the staff indicated that they were aware of what constituted poor care/ abuse and action that they would take. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 16 One of the senior staff had recently completed a trained the trainer course and would be providing staff training/ update and as part of their induction process. The manager reported that the service has two’ dignity at work’ champions who observe/monitor staff practices and report any issues to the manager so these can be sorted out. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides the service users with a high standard, clean and wellmaintained accommodation that meets their needs. The infection control procedures at the home are good and ensure that the service users are protected. EVIDENCE: We walked around the service as part of the visit where a number of bedrooms, communal lounges, bathrooms, kitchen and laundry were viewed. This is a purpose built service that has been recently opened following registration with the commission. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 18 All areas at the home were in a very good decorative order, clean, bright and homely. It was evident that a lot of thoughts had gone in choosing wall pictures that depicted local scenes and articles of interests. Furnishing was of high standard and appropriate to the needs of the service users. The bedrooms were personalised and equipment such as hoists, assisted baths were available. All the bedrooms were fitted with a wet area/ shower facility that the staff said worked well and the service users liked. We looked at the laundry that was fitted with appropriate washing machines and driers. The linen bags were colour coded to ensure that soiled/ infected laundry are maintained separately. Staff practices on the whole indicated that they were aware of infection control procedures. Equipment such as gloves and aprons were available to support staff practices. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers are adequate to meet the present needs of the service users. The recruitment process is inadequate as information and record about all necessary checks had not been completed, to ensure that people are suitable to work with older people. There is an ongoing training programme in place to ensure that staff have the skills to deliver care safely. EVIDENCE: The home has a duty roster for nurses and carers and a separate roster for ancillary workers. A sample of the staff roster indicated that there are one trained staff and 3 carers on the early shifts, and 1 trained staff and 3 carers on the afternoon shifts. The night staff included 1 trained staff and 1 carer. Staff and service users spoken with confirmed that they felt that there were adequate staff to meet their needs. The service users were all accommodated on the ground floor at present. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 20 The information we have received shows that the home employs 7 permanent carers and 4 of them have achieved NVQ 2 and above. There was a detailed induction record in one of the staff record seen. Information from the AQAA indicated that as part of the improvement the service plans to complete training for in-house trainers. To ensure all staff have the required mandatory training. To encourage all staff to undertake NVQ training. The home has a recruitment procedure and the manager interviewed all the applicants. A sample of three newly recruited staff seen indicated that checks were undertaken and references sought to employment. However this was not consistent, two of the staff records contained two appropriate references and one contained one reference. The manager stated that she would be chasing this up. However, two written references must be obtained prior to employment, to ensure that the applicant is suitable to work with vulnerable people. The records of Criminal Record Bureau CRB) checks available at the service were also inadequate. The manager reported that the records are kept at their head office. We asked for clarification for a CRB for one of the staff as this was not available and the manager received an email to say that this had been completed. The registered person must ensure that accurate records as required by regulations are available as required. The CRB records must contain the disclosure number and the dates that these were completed. Two references must be available as part of the recruitment process including one from the last employer. The manager had some records of the trained nurses checks that were undertaken to ensure that their registration was current. A record of all the registered nurses checks was not available and this must include a copy of the registration as this was not available. The home has an ongoing training programme in place. Recent training records seen included dementia care, infection control, health and safety, nutrition and food hygiene. Five trained staff have completed medication management update. Some of the new staff had not completed moving and handling, the manager confirmed that these staff did not undertake moving and handling of the service users. It was reported that this training has been booked and would be completed soon with the other new staff. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a manager who is highly regarded and has clear lines of accountability for the service. The financial interests of the service users are safeguarded through satisfactory accounting. The process of seeking the service users’ views is inadequate at present due to change in the management at corporate level. There is a satisfactory procedure in place to ensure the health and safety of the service users is promoted. Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has a registered manager who is experienced in the care of people. The staff and service users commented that they would approach the manager with any concerns. It was evident that there were clear lines of accountability for the service. The manager undertook monthly audits of accidents and complaints. The home has policies and procedures in place to inform practice, however all of these had not been reviewed in the last year according to the AQAA. The manager must ensure that these are completed at regular basis to ensure that all information are up to date and they meet with current regulations and guidelines. The manager reported that the service users had their personal allowances that were banked in their individual names in a corporate account. They had signed an agreement with the service for items such as chiropody, hairdressing, toiletries that are deducted for their account. No money was held on behalf of the service users at the home. We looked at the internal audit system that the home has in place to monitor practices. The manager carried out an audit of falls and complaint s and records of these were available. Information we have received indicated that there have been some changes in the management structure above the home’s manager level in the recent months. The service has changed their responsible individual and we have not received confirmation of the new responsible person. This information must be sent to the commission in writing. We looked at the unannounced visits that have been undertaken as part of monitoring the care delivery and ensuring that the home was meeting its commitment as per the statement of purpose. Records showed that these were completed in November and December 08 and no recent reports were available. The environmental health officer visited in January 09 and the home was awarded an excellent for their kitchen. All the staff were proud of this achievement. Information we have received indicated that there is an ongoing programme for the servicing of fire equipment, hoists, wheelchairs, lift and emergency lighting. All these had been in place for the last six months as this is a new Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 23 service. All substances that are hazardous to health maintained safely and were kept locked. (COSHH) were kept Hamilton House Care Centre DS0000072741.V374379.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 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP7 Regulation 13(4) 15 (1) Requirement The registered person must ensure that following assessments detailed care plans are put in place to demonstrate how the service users’ assessed care needs would be met. The registered person must ensure that the service users health and personal care needs are fully met at all times including detailed dietary assessments and care plans to meet those needs. Timescale for action 30/04/09 2. OP8 14(1) (a) Schedule 3 (o) 30/04/09 3 OP29 19 (1) The registered person must 30/04/09 ensure that all necessary checks are in place prior to employment including references, evidence of qualifications and evidence of full CRB. The registered person must ensure that effective quality assurance process is in place including monthly monitoring visits to the service to monitor and ensure that residents’ needs are met consistently. Records of DS0000072741.V374379.R01.S.doc 4 OP33 26 30/04/09 Hamilton House Care Centre Version 5.2 Page 26 these must be available at the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hamilton House Care Centre DS0000072741.V374379.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Hamilton House Care Centre DS0000072741.V374379.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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