Inspection on 22/01/07 for Hendford Nursing Home

This inspection was carried out on 22nd January 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 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

Hendford Nursing Home 30/08/07

Hendford Nursing Home 29/11/05

Hendford Nursing Home 07/06/05

Hendford Nursing Home 11/08/04

Hendford Nursing Home 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Hendford Nursing Home Howell Hill Grove East Ewell Epsom Surrey KT17 3ER Lead Inspector Denise Debieux Unannounced Inspection 09:30 22 January 2007 nd 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 Hendford Nursing Home DS0000013326.V325417.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. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hendford Nursing Home Address Howell Hill Grove East Ewell Epsom Surrey KT17 3ER 020 83937891 020 83932886 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) Jesyem Medicare Limited Mrs Maria Christopher Care Home 34 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (34), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (34) Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the residents accommodated, up to 34 may fall within the category of either DE(E) or MD(E) Up o 3 residents may fall within the category of either DE or MD. The age range will be: over 65 years with up to 3 under the age of 65 but not below 59 years of age. 29th November 2005 Date of last inspection Brief Description of the Service: Hendford is a large detached house in the village of East Ewell. It offers accommodation with nursing for thirty-four older people with dementia and mental health needs. There are two large lounges for service users use. Accommodation is arranged over two floors with the majority of twenty single en-suite bedrooms and seven shared bedrooms. There is an enclosed garden at the rear of the house, which is accessible to the service users, and patio furniture is available in the good weather. Car parking is available at the front of the house, which has been extended during the refurbishment programme. Fees range from £525 - £650 per week. This fee does not include hairdressing, newspapers or transport. This information was provided on 15/01/07. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 8 hours and was carried out by Denise Débieux, Regulation Inspector. Mrs Maria Christopher (Registered Manager) was present as the representative for the establishment. A tour of the premises took place. Five of the thirty-four service users and five on-duty staff were spoken with during the visit. Seventeen relatives’ survey forms, four health and social care professionals survey forms and eight service user survey forms were received prior to the visit. In addition, ten staff survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment and training records, health and safety check lists, menus, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit and the service users, staff, relatives and health and social care professionals who participated in the surveys. What the service does well: The staff work hard to ensure that service users’ needs are met, whilst encouraging and enabling service users to maintain their independence where possible. One service user commented ‘I am happy here. Everybody is kind to me. The girls are doing a great job’ and another that ‘I’m alright here. They are good to me’. All interactions observed between the management, staff and service users evidenced that the home has a close and caring staff team. When asked what was the best thing about working at Hendford Nursing Home, one member of staff answered ‘Always clean and tidy. Friendly atmosphere. I have been treated with respect by the matron and the proprietor and I am being listened to’ and another answered ‘Being able to contribute to people having quality of life and seeing the love and care shown to residents’. Positive comments were also received from relatives that were surveyed. Comments included: ‘Our relative always appears clean, tidy and well cared for’ and ‘The low staff turnover is a major factor in the high quality of care Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 6 received by my relative. The home is always welcoming, with a good atmosphere and I am very satisfied’. 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. Hendford Nursing Home DS0000013326.V325417.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 Hendford Nursing Home DS0000013326.V325417.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: The inspector was advised that the clinical manager or one of the trained nurses would visit a prospective service user and carry out a pre-admission assessment. Information from other health care professionals and relatives is also obtained, if available. The home then hold a pre-admission meeting with, if possible, the service user and/or their representative, the care manager and a representative from the home. At this meeting the proposed care plan is discussed and agreed prior to the service user moving into the home. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 9 Three care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out, prior to admission, to ensure that the home could meet the service users’ identified needs. New regulations came into force last year that require additional information to be included in the service users’ guide and that all service users be given a full breakdown of their fees. These regulations were discussed with the management during this visit and the inspector was advised that the manager will be reviewing their documentation against the new regulations. Hendford Nursing Home DS0000013326.V325417.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 and 10 Quality in this outcome area is good. 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 to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. The arrangements for health and personal care ensure that service users’ privacy and dignity are respected. EVIDENCE: The care plans sampled during this visit were all based on comprehensive preadmission assessments and had been drawn up shortly after the service users’ admission to the home. The care planning system at the home includes care plans for each identified need and requires that goals or objectives be established, together with staff actions to be taken to meet these goals. The daily notes do not always evidence the actions staff are taking to meet individual needs and actions to reduce identified risks are not always Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 11 incorporated into the care plans. A recommendation has been made that the care plans be reviewed. From observations made at this visit it was clear that the staff have a good knowledge of the needs and preferences of the service users. All relatives and health and social care professionals surveyed said that they were satisfied with the overall care provided at the home. One relative added: ‘I am more than happy with the standard of care, cleanliness and numbers of staff, who I find capable, friendly and approachable.’ The medication administration records were sampled, the records were well kept and any occasions that medication had not been given, or had been refused, were clearly recorded. Medication storage was also checked and found to be in order and the controlled drugs register was well maintained and tallied with the controlled drug count. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all personal care was provided behind closed doors. All interactions observed between staff and service users were seen to be caring and respectful and the service users were obviously at ease and comfortable with the staff on duty. Service users surveyed felt that they received the care and support they required with one service user commenting ‘They are very good to me’. Hendford Nursing Home DS0000013326.V325417.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ongoing development of the home’s activity provision is leading to a more varied and individualised activity programme. Contacts with family and friends are encouraged. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: The home employs two activity organisers and it was clear to the inspector that the home recognises the importance of meaningful activities for service users with dementia. Each year the home chooses a slogan which relates to areas the home wishes to develop. This year the slogan is ‘Activity Based Living’ with the aim that all service users will have activity centred lives. The manager has linked with a national organisation for providers of activities and ideas are sought and encouraged from service users, relatives and staff. During this visit many of the service users were seen to be engaged in purposeful activities, both individually and in groups. The staff have carried out assessments and obtained histories of hobbies and activities that service users are interested in. The individual activity schedules, where appropriate, can also include some involvement in the day to day running of the home. E.G. one service user, who previously worked for many years in catering, Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 13 enjoys taking responsibility for laying the tables for lunch, with staff assistance where needed. Organised activities include ball games, ‘sing-songs’, dancing and local musical entertainments. Of the service users surveyed six answered that there are always activities they can take part in, one answered ‘usually’ and one answered ‘sometimes’. Service users surveyed commented especially on how much they enjoyed the ball games and musical entertainment. There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships both inside and outside the home. Relatives surveyed all said that the staff welcome them in the home at any time, with one adding ‘The home is always welcoming, with a good atmosphere and I am very satisfied’. The manager is also exploring different ways for the service users to be involved in decisions made at the home. For example, when new curtains were being chosen for the lounge, the manager obtained swatches that the service users could look at and feel and then, with service users that were unable to express a preference, the staff used observations of the service users’ reactions to the different swatches to establish their preference. Menus were sampled and seen to be varied and well-balanced. The supper time meal was taking place during the visit and the food was presented in an appetising manner, with ample staff available to assist service users where needed. Of the eight service users who returned comment cards, all said that they liked the meals at the home. Hendford Nursing Home DS0000013326.V325417.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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. Policies and procedures are in place to protect service users from harm or abuse but current recruitment practices must be revised as they are placing service users at risk of potential harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives and is also included in the service users’ guide. The home also has a ‘Whistle Blowing’ policy in place and basic awareness of the protection of vulnerable adults is included in the home’s induction training. A copy of the latest ‘Surrey Multi-agency Procedure for the Protection of Vulnerable Adults’ is available in the office. Of the ten staff members surveyed, all stated that they would report any suspicion or report of abuse to the person in charge and all confirmed that they had received ‘vulnerable adult’ training. All service users spoken with told the inspector that they felt safe at the home. Concerns regarding staff recruitment are covered in more detail in the ‘Staffing’ section of this report. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: During the tour of the home the premises were seen to be well maintained with service users able to freely access all areas. All personal rooms seen were individualised to the service users’ wishes and were seen to contain many personal items and mementos. Since the last inspection there have been many improvements to the home. The boiler and central heating system has been totally replaced; a ground floor bathroom has been fully refurbished; new curtains and carpets have been fitted in some of the communal areas and the first floor bedrooms have all been redecorated. Over the next few weeks the newly decorated bedrooms will have the work completed with the fitting of new built-in wardrobes and Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 16 new curtains. Double glazed windows are also on order and booked to be fitted soon. The requirement made at the last inspection has been met. The gardens were well kept, with separate seating areas provided for the use of service users and their visitors in warmer weather. On the day of inspection the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. Laundry facilities are sited on the ground floor with facilities suitable for the service users accommodated at the home. The laundry is staffed seven days a week. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ needs are met by the numbers and skill mix of staff. Action must be taken to improve the staff recruitment procedures to ensure that the service users are not placed at unnecessary risk of harm or abuse. The home has an ongoing staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times but the staff induction programme must be revised in line with the Skills for Care mandatory induction standards and staff must be appropriately supervised pending receipt of a CRB check and for the duration of their induction training. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the service users at the home. Of the eight service users surveyed, six stated that staff are always available when needed, one answered ‘usually’ and one answered ‘sometimes’. Fifteen of the seventeen relatives surveyed felt that there were always sufficient numbers of staff on duty. During this visit the recruitment files of three recently recruited care staff were sampled. The files were seen to contain a current photograph and an application form. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 18 However, none of the required recruitment checks had been carried out in full, specifically: • full employment histories had not been obtained; • each application form had gaps in employment with no written explanations; • two files did not have two written references; • two files did not have a reference from the last place of employment working with vulnerable adults; • no files had written confirmation of reasons for leaving previous employment working with vulnerable adults; • None of the three staff members had been checked against the Protection of Vulnerable Adults (POVA) register and CRB certificates had not been applied for. The home use their own induction programme and were not aware that, in October 2006, new mandatory induction standards were introduced by the Skills for Care organisation. Consequently, the three new staff members had also not been provided with the required induction training following their employment. The management were not aware of amendments to The Care Homes Regulations 2001, which came into force in July 2004 and related to staff recruitment and required supervision of staff prior to the receipt of a valid CRB certificate; were not following the Department of Health’s POVA guidance and were not aware that staff cannot be employed without a check being carried out of the POVA register. Staff recruitment procedures at the home must be reviewed as a matter of urgency to ensure that service users are not placed at risk of potential harm or abuse. Immediate requirements were made on the day of this visit and additional requirements have been made regarding staff induction and supervision. During this visit it was apparent that there is a firm commitment to ongoing training at the home. The Nursing and Midwifery Council has approved the home as a learning environment and the home is linked to Kingston University as a centre for learning, which allows them to have student nurses at the home on placements. Over 50 of the care workers are now qualified to National Vocational Qualification (NVQ) level 2 in care, with a number going on to study at level 3. Two of the trained nurses are registered to begin the Registered Manager’s Award training. The training records evidenced that all mandatory training and updates are provided promptly. Additional training is provided that is relevant to the needs of the individual service users at the home. Staff surveyed all stated that they were never asked to carry out work that they had not been trained for. One member of staff commented that there were always study days and short courses available and another that the training was good. All staff stated that they had been provided with the General Social Care Council’s code of conduct and practice. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 19 Service users spoken with were complimentary about the staff at the home. Of the eight service users surveyed, six stated that staff always listen and act on what they say and that the staff are always available when they need them. One relative commented ‘The low turnover of staff is a major factor in the high quality of care received by my relative.’ All interactions observed between the staff and service users were caring and respectful. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the clear management approach at the home which provides an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users and their relatives. Policies and procedures are in place to protect service users’ financial interests. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: The manager completed her Registered Manager’s Award in July 2006 Her management style is inclusive and the service users benefit from the ethos, leadership and clear management approach of the home. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 21 A total of ten staff questionnaires were returned to the inspector on the day of this visit. From observations made on the day and from comments made on the staff questionnaire it is clear that the home have a close and happy staff team. When asked what was the best thing about working at the home, staff comments received included: ‘Nice home, friendly atmosphere. Management is very helpful’ ‘Friendly atmosphere. I have been treated with respect by the matron and the proprietor and I am being listened to’ and ‘The team work is good and the manager cares for us’. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users, GPs and other health and social care professionals. There are regular relatives’ meetings and monthly quality assurance reviews (Regulation 26 visits) now take place. The home also has an external audit carried out that is related to their being registered to have nursing students on placement. No valuables are kept in the home and any money that is spent by the service users (i.e. for hairdressing, newspapers and transport) is invoiced on a monthly basis. The manager is the health and safety officer and there is also a buildings maintenance consultant who is overseeing the extensive building works and improvements. All required safety monitoring checks, fire drills and safe working practice training and updates have been carried out. Staff were observed to be following appropriate health and safety practices as they went about their work. All interactions observed between the manager, staff and service users were inclusive, caring and respectful. Hendford Nursing Home DS0000013326.V325417.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19(1)(b) Schedule2 Requirement The registered person must not employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained 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). 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) retrospectively for all staff employed since 26th July 2004. The registered person must ensure that any staff that do not have all the required checks and documentation in place, are DS0000013326.V325417.R01.S.doc Timescale for action 22/01/07 2 OP29 19(1)(b) Schedule2 29/01/07 3 OP29 18(3) (a-b) 19(1)(b) 22/01/07 Hendford Nursing Home Version 5.2 Page 24 Schedule2 4 OP29 18(1) (c)(i) 19(1)(a-c) Schedule2 5 OP29 OP30 19(9) (10)(a)(b) (11)(a-c) 18(2)(i-iii) 6 OP30 18(1) (c)(i) closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. The registered person must 22/01/07 ensure that all staff responsible for staff recruitment are aware of, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. Where a new worker is permitted 22/01/07 to start work on the basis of a POVAfirst check but prior to receipt of a CRB certificate and for the duration of a new worker’s induction, the registered person must: • Appoint a member of staff (‘the staff member’) to supervise the new worker; • So far as possible, ensure that ‘the staff member’ is on duty at the same time as the new worker; and • Ensure that the new worker does not escort service users away from the care home unless accompanied by ‘the staff member’. (Reference The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must 22/02/07 ensure that new workers are provided with induction training that is compliant with the Skills for Care mandatory induction standards and procedures. DS0000013326.V325417.R01.S.doc Version 5.2 Page 25 Hendford Nursing Home RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that the home carry out a review of service user care plans to establish that all elements of the National Minimum Standards 7 and 8 are included. Hendford Nursing Home DS0000013326.V325417.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hendford Nursing Home DS0000013326.V325417.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. Re-publishing this information is in breach of the terms of use of that website. 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