Inspection on 19/10/06 for Homefield House

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Homefield House 18/09/07

Homefield House 22/11/05

Homefield House 27/07/05

Homefield House 31/01/05

Homefield House 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Homefield House 57 Homefield Road Old Coulsdon Surrey CR5 1ET Lead Inspector Michael Williams Key Unannounced Inspection 19th October 2006 10:50a 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 Homefield House DS0000043327.V310852.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. Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Homefield House Address 57 Homefield Road Old Coulsdon Surrey CR5 1ET 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) 01737 551880 01737 551681 London Borough of Croydon Acting Manager in post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Homefield House is owned and managed by the London Borough of Croydon. A number of large bedrooms have been converted into single rooms or lounge space so the home now has thirty-five places. The Local Authority is also changing the homes stated purpose; currently in transition it now offers intermediate care and social ‘re-ablement’ care, that is rehabilitation, for an increasing number of service users as the number of permanent service users diminishes. The home also continues to provide respite care. The home is a purpose built detached property situated in a quiet residential area of Old Coulsdon. There are currently separate lounge and dinning areas on each floor of the home and it has a well-equipped kitchen on the ground floor. Sufficient numbers of bathroom and toilet facilities are conveniently located throughout the home. Laundry and sluicing facilities are also available on each floor. The home has a large garden and there is limited space for parking. Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was conducted on a warm, Autumn day in 2006 and included the distribution of questionnaires to relevant parties including residents, their relatives, care managers, health care professionals and all staff in the home. From this the Commission received nine replies including three from residents, five from families and one from a doctor. All were very positive about the Home and the quality of care provided by staff. The site visit was from late morning until tea-time and most service users had an opportunity to talk to the inspector; several relatives were visiting on this day and they most helpfully commented on the procedures for admitting new or respite residents. Comments were also received from visiting professionals including a Nurse and a Physiotherapist. Representatives from the whole staff team were interviewed including care staff, catering and cleaning staff and a maintenance person. Not all the staff in Homefield House are now employed by the London Borough of Croydon; catering and housekeeping is now managed by a private company. Whilst not seeking to influence the manner in which a service is provided the Commission is nevertheless concerned that the Home’s Manager loses control of certain aspects of the management of the home including the appointment of ancillary staff and in particular the safety checks required of all staff. The Home’s manager also loses direct day to day management of kitchen and cleaning staff. The Commission will need confirmation that National Minimum Standards can be met and Statutory Requirements complied with - including any information that the Commission might reasonably require to be produced by the registered persons under the provisions of Section 31 of The Care Standards Act 2000. Although there are a number of sections that are assessed as adequate rather than good the overall impression is good because this is a well run home where shortcomings are identified and addressed. What the service does well: The service users were certain that this home meets its stated aim to the full; that is, “to provide residential care in a safe and friendly environment”. Service users say the staff, especially the permanent staff, are very kind and caring and residents say they don’t want to move. It was also very reassuring to hear that residents who are admitted for short stay, respite or rehabilitation, say they have been pleasantly surprised by the quality if care and are less fearful of the prospect of moving into such a care home in the future. The staff are therefore to be commended for achieving this really positive outcome for users of the service. Diversity is managed in much the same way as it is in many other homes; there are staff from a variety of nations, the building is equipped to assist Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 6 residents with mobility and sensory problems, catering staff will provide meals reflecting a range of choices and nationalities, on the day of inspection stir-fry chicken or chicken curry were the two main choices; where residents choose to make known their sexual orientation the staff will respect their lifestyle. 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. Homefield House DS0000043327.V310852.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 Homefield House DS0000043327.V310852.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social care and health care needs are assessed prior to admission; these needs are then translated into care plans and are reviewed and revised periodically. This ensures that service users will know that staff in the home will be able to meet their changing needs. The home also has in place arrangements to provide rehabilitation support and these service users can also be assured that their needs will be assessed prior to admission to ensure their placement in this particular home is appropriate. EVIDENCE: A sample of case notes was checked. The person in charge, some staff and relatives were interviewed during the course of this and the previous inspections; the service users also advised the inspector of their experiences at the time of admission. The pre-admission assessments include general information about each service user, details of their background medical and social history and comprehensive Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 9 details of specific issues such as mobility nutrition, diabetes, continence, medication and diversity needs or choices. Service users, with their representatives, assist in the compilation of these case notes. The home’s management team has taken the initiative and arranged meetings with senior care managers to discuss the issue of pre-admission information and referrals. These meetings are very important to ensure the home’s role and limitations are clearly known to all relevant agencies and inappropriate placements can be avoided and the person in charge is now confident that only appropriate referrals are being made since some clarity was brought to the admission criteria. In particular the home does not admit service users with nursing care needs that cannot be met by a visit once each day by a District Nurse. Areas of strength are preparation for admission and information provided and matters requiring improvement are none so this section, about choice, is assessed as good. Homefield House DS0000043327.V310852.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Plans are in place for each service user. This means that, so long as the placement was appropriate, the needs of service users can be met. Medication can either be administered by the care staff or they will support service users to hold and administer their own medication in order to maximise their independence. Service users are treated with respect and dignity. EVIDENCE: A sample of residents case files were read; residents and relatives were interviewed; staff and visiting professionals, a Nurse and a Physiotherapist, offered their opinions and the manager also explained how they aim to met the social and health care needs of all residents. The administration in this home is very good and the case files were in good order despite the range of services on offer – some residents are long stay others admitted for respite and others for rehabilitation support before returning home - so the case files need to be well managed and they are. Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 11 Pre-admission information is in place and this helps direct the in-house assessments and care planning. A range of documents are required to be maintained for each service user including items such a photograph, basic personal data, health and social care needs, professional and family involvement and so forth. Care plans and reviews are in pace for each service users and the daily notes indicate that staff are providing suitable care and support for each service user. During the inspection it was noted that the home’s staff make prompt and direct contact with health care professionals such as a Nurse or Doctor if the need arises as it did on the day of inspection. The visiting Nurse and Physiotherapist and an ambulance driver all attested to the professional manner in which this home is being run. No errors were identified in the procedures for recording, storing, administering and returning medication. In most instances staff assist residents with their medication but for those residents intending to return home the care staff can support residents in looking after their own medication in their rooms. The privacy of residents was compromised in several respects; bedroom door were not suitable, some were mortise deadlocks whilst others were toilet-style locks, which can be easily opened with a coin. It was also noted that one of the bathroom door locks was not operating properly so the door could not be locked when the bathroom was in use. Areas of strength are the well managed documentation to support care practices and the residents’ views that they are well cared for and as there are no matters requiring improvement in this section, about health and social care, it is assessed as good. Homefield House DS0000043327.V310852.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable setting for service users to engage in social and cultural activities as they choose and in accordance with their expectations for the home including any ‘diversity’ issues. The staff assist and encourage service users to lead as fulfilled lives as they wish or their frailty allows. Service users are encouraged and given every opportunity to maintain contact with family and friends and the community. A full and wholesome diet is available for all service users. EVIDENCE: The most important aspect of this section is that the residents said they were very happy in Homefield House, they want to stay and they don’t want any changes made. This reflects the quiet, tranquil atmosphere evident during this visit. There is ample space for residents to sit where and with whom they please. Staff were with them throughout the day and often engaging them in some activity or conversation. It was also pleasing to hear residents in the ground-floor lounge supporting each other and chatting about their news and views – clearly a group of residents who are getting on well together. It is expected that a care home will support residents to maintain links with their family, friends and the wider community and this appears to be the case. Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 13 Visitors are welcomed, residents still go out to visit their family and friends when they wish and representatives from the community come in regularly including church members and entertainers. Several visitors were on site to confirm that they may visit freely and are welcomed by staff. The manager advised the inspector that all residents use English as their language of choice although one or two are not English by birth. Other aspects of diversity were discussed such as the accommodation of residents who may have sensory or mobility problems – the home seeks to meet such needs whenever possible. Matters of sexual diversity were also discussed, given the age of the client group many would reflect on how different things were when young but in Homefield they will be treated with tolerance and forbearance whatever their lifestyle or sexual orientation. Areas of strength are the residents’ universal opinion that this is an ideal setting in which to be cared for and as no matters requiring improvement arise in this section, about daily life, it is assessed as good. Homefield House DS0000043327.V310852.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 inspected at least once during a 12 month period. 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. Arrangements are in place for service users and their representatives to either complain or compliment the service. Effective procedures are in place to deal with complaints. Arrangements are also in place to protect the vulnerable service users. EVIDENCE: Questionnaires were sent out to residents, cares and families, professionals and to professional visions as well as staff in the home. Records were checked and residents interviewed. Service users and their visitors confirmed that with present arrangements in place, to complain or make representations, they are confident their opinions and concerns are dealt with in a professional and thoughtful manner. A record of complaints is in place. No complaints arose during the course of the inspection. In contrast several complimentary comments were made by those people interviewed. Whilst no complaints were made during this inspection or the previous inspection two suggestions were made to the CSCI, one was about improving the entrance hall and the other was about improving television reception especially in service users’ bedrooms where reception is poor at the moment. Both suggestions were passed on to the home and the person in charge confirmed that these two suggestions are already being followed up. The home has an up to date copy of the local authority’s procedures for dealing with allegations of abuse but no such issues have arisen since the previous inspection. Staff were aware of their responsibilities to protect service users Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 15 and deal promptly and efficiently with any allegations or suspicions of misdemeanour but not al staff recalled the importance of referring such matters to the local authority care management team before making anything other than brief enquiries to clarify the allegation. A requirement is made to ensure the guidance is readily available to, and followed, by all staff particularly those staff who may be in charge of the unit as part of their duties. Areas of strength are positive approach to managing complaints and concerns and the positive feedback from residents but there is one matter requiring improvement. The procedures for referring allegations of abuse to the local authority care management team; refresher training is already booked and the Commission is confident this training and guidance will be acted upon if the need arises. So this section, about complaints and protection, is assessed as good. Homefield House DS0000043327.V310852.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained and comfortable environment. It was clean and comfortably warm at the time of inspection. The kitchen was however in need of a deep clean. EVIDENCE: This is a purpose built care home with a wide range of communal rooms and a variety of bedrooms of different sizes (although none of the bedrooms have ensuite toilets). The home is maintained safely and no hazards were identified in the general environment but a requirement is made to provide an action plan to deal with the ‘deep cleaning’ of the kitchen. Although the mesh filters are being cleaned periodically the vent-trunking above the cooker is dirty; the walls above head height are dirty and the edges of the floor near the walls are also dirty. The manager appears to be dependent upon the private housekeeping contractors to maintain a clean environment – but they according to the person in charge, have limits to the work they will undertake Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 17 in the kitchen. This appears to be an example of the confusion and poor outcome that can arise when management is divided in the manner in which it is in this home. Some furniture was old and worn and must be repaired or replaced - dining tables for example, where the surface laminate is very worn and lifting, are still in use and look unsightly in an otherwise pleasantly decorated environment. This home cares for people who have recently been in hospital and are preparing to return home so their conditions vary from considerable immobility and dependency to greater mobility and independence. The home has in place a range of facilities to support this including various aids and adaptations such as a domestic scale kitchen on the first floor for retraining domestic skills and aids in the toilets and bathrooms to ensure the safety of service users. The bedroom doors are being replaced but the locks are not suitable, they are neither safe nor provide adequate privacy. One bathroom has a lock that is not working properly. A requirement is made to fit suitable door furniture to all bedroom and bathroom doors. Areas of strength are homeliness of what is very large care home and matters requiring improvement are kitchen hygiene, door locks and replacement of furniture. In view of these shortcomings and despite the fact this is generally a safe and well maintained building this section, about the environment, is assessed as only adequate at this time. Homefield House DS0000043327.V310852.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 at least once during a 12 month period. 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. Care staff and ancillary staff were present in sufficient numbers and with the skill mix to meet service users’ needs on the day of inspection. However there is undue reliance upon temporary, agency staff and not permanent staff as the residents prefer. A training programme is place and this provides a comprehensive schedule of induction and ongoing training for all staff. This ensures that service users’ needs can be met in a safe and well run home. Whilst the recruitment of staff is basically sound the home could not demonstrate that all checks have been made with the potential to compromise service users’ well being. EVIDENCE: Staffing levels for existing care homes must be no less than the guidance issued by the previous regulating bodies and that was the case on the day of the visit (the guidance is that there be, as a minimum, 13 day-care hours per resident per week - a total of 455 day care hours; the equivalent of four carers for each day time shift when the home is full). The home is not equipped for, and staff are not trained for, specialist forms of care such as dementia care and nursing care because these fall outside its registration category. The home is however considering a review of registration so as to extend registration to include dementia care. The training programme is very good and includes a wide range of opportunities, including basic elements such as fire safety and moving and Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 19 handling (lifting) and important issues such as protecting elders from abuse. Arrangements for staff supervision are in place and regular staff meetings are being held. Staff are given training in matters of safety such as handling chemicals, fire safety and maintaining a safe environment. Housekeeping staff, those that do the cooking and cleaning and employed by a private company contracted to provide these services to the home; the person in charge does not therefore have full control of the staff team nor some aspects of the running of the home such the cleaning of the kitchen; preparation of menus and kitchen records; training and supervision of housekeeping staff and so on. This is a matter the Commission will keep under review. Under the next section, management, a requirement is made to confirm that the home can continue to meet National Minimum Standards and Requirements issued by the Commission despite losing some control of the staff team and their work. It was noted that this home relies upon a large proportion of agency care staff; whilst some are long term agency staff and therefore familiar with residents’ needs this is not always the case. The person in charge states that she has been given permission to start recruiting for permanent staff and this should proceed without delay. It is noted that in the feedback to the Commission residents very much appreciate the care provided by staff but they are concerned about the many temporary staff they see. The Commission was advised there are typically 50 agency staff on duty as there was on the day of inspection. Areas of strength are the very caring manner in which staff go about their duties and the substantial support and training provided by the LB Croydon for staff in the home but matters requiring improvement include the need for sufficient numbers of permanent staff to be employed – so this section, about staffing, is assessed as adequate. Homefield House DS0000043327.V310852.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has retired so a replacement is still required as soon as practicable if the home is to be managed in a way that will meet service users’ needs. It was clear that the staff team, including the senior staff are managing the home with the intentions of providing for the best interests of the service users. EVIDENCE: The retired manager has still not been replaced by the Commission is aware that this is due in part to the reorganisation of LB Croydon’s care homes under the ‘New for Old’ programme - which means managers may transfer from home to home in the interim; nevertheless a permanent manager who is registered with the Commission must be put in place as soon as practicable and this must be the case if the home is seeking to extend its registration to Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 21 additional registration categories such as dementia care. In respect of the general management of the care home the introduction of private company to manage the catering and cleaning of the home, and the staff who will undertake the work, is no longer under the direct managerial control of the Registered Manager. The providers must confirm that this will not inhibit the manager from complying with National Minimum Stands and Care Home Regulations. It is the opinion of service users and visitors that this home is being run in the best interests of those services users. The home is being safely run, according to residents’ statements, by a dedicated and caring staff team. The arrangements for handling residents’ money, when handed into the office, have been checked on a number of occasions by the Commission and appear satisfactory. The accounts and cash are periodically audited independently in addition to the Commission’s checks. In respect of the health and safety of residents the home is well managed and no hazards were identified during this visit – with the exception of the bedroom door-locks, which have unsuitable deadlocks that must be removed or rendered unusable. The doors are being replaced with doors providing a higher standard of fire resistance and is noted that the glazed windows above the doors also need to be replaced with fire resistant glass or in-filled with fire resistant panel. A requirement is made to complete this work without delay whilst acknowledging it is underway. In view of the introduction of a private company to undertake certain duties within this care home the providers must confirm that they can continue to meet National Minimum Stands and comply with requirements despite losing direct control of the housekeeping aspects of this home. Areas of strength are the high esteem in which the home is held by residents and this reflects good day to day management of the home but matters requiring improvement are the need for a permanent, registered manager; completion of fire safety work; replace unsuitable door locks and confirmation that despite the use of private contractors for housekeeping the registered person can and will comply with National Minimum Stands and Regulations. So this section, about administration and management, is assessed as adequate. Homefield House DS0000043327.V310852.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X 3 1 Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8 Requirement Registered Manager: following the retirement of the registered manager a replacement must be employed without unreasonable delay and an application for registration submitted to CSCI. This is an outstanding requirement from 30/10/05. Environment: Furniture that is worn must be repaired or replaced including for example dining tables where the laminate is worn away. This remains outstanding from 30/05/06. Environment: Bedrooms and bathrooms doors must be fitted with suitable door locks. Fire safety: All requirements issued by the Fire Safety Authority, including the replacement of doors and glazed panels, must be competed without undue delay. This also affects standard 38 about health and safety. Timescale for action 28/02/07 2. OP19 23(2)b 30/12/06 3 OP19 16(2)c 30/12/06 4 OP19 OP38 23(4) 30/12/06 Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 24 5 OP26 16(2)j Hygiene: The kitchen is to undergo a through, deep, clean including all areas not readily accessible to the kitchen staff on site. Protection: All staff must receive periodic refresher training in the procedures to be followed when abuse is suspected. It is acknowledged that training is already planned for. Staffing: It is recommend that sufficient permanent staff be employed to ensure continuity of care for service users. Safety: Unsuitable deadlocks on bedrooms doors must be removed and replaced with suitable locks or they must be rendered unusable. 30/12/06 6 OP18 13(6) 30/12/06 7 OP27 18(1)a 28/02/07 8 OP38 23(4) 30/12/06 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 OP31 Good Practice Recommendations Management: It is recommended that the providers confirm with the Commission that despite the employment of a private company to manage housekeeping on their behalf the home can still meet National Minimum Standards and all regulatory requirements. Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 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 Homefield House DS0000043327.V310852.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!