Inspection on 10/01/07 for Homeleigh

This inspection was carried out on 10th 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

Homeleigh 21/09/09

Homeleigh 04/11/08

Homeleigh 07/11/07

Homeleigh 25/01/06

Homeleigh 18/10/05

Homeleigh 17/03/05

Homeleigh 27/04/04

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 Homeleigh Avenue Road Erith Kent DA8 3AU Lead Inspector Lorraine Pumford Unannounced Inspection 10th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Homeleigh DS0000006793.V307690.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. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Homeleigh Address Avenue Road Erith Kent DA8 3AU 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) 01322 339691 01322 350291 allisonp@kcht.org.uk www.kcht.org Kent Community Housing Trust Care Home 48 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (32) of places Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to four (4) placements may be for short term/respite care. These placements are to be on the ground floor and may not include the category DE(E). 25th January 2006 Date of last inspection Brief Description of the Service: Homeleigh is a large detached building situated in a pleasant residential area of Erith. It is near to local shops and facilities, and has bus routes and train stations within easy travelling distance. It is owned and managed by Kent Community Housing Trust (KCHT), which is a charitable (not for profit) Trust, and who have other care homes for older people within the region. The home is set into a hillside, and has four floors, of which 3 are for accommodation. The top (3rd) floor is used as the premises for KCHT’s Bexley Regional Office. The ground and first floors include bedrooms and communal areas for older people (not in any other category of registration), and includes up to 4 beds for respite or short term care. There are also 4 rooms kept on the ground floor for older people with a high level of visual impairment. The 2nd floor has bedrooms and a communal lounge/dining room, and is used specifically for older people with dementia. There are additional safeguards in place for their safety. All levels can be reached via a passenger lift. As the home is on a hillside, the gardens are accessed from the first floor at the rear of the building, and there is a spacious patio area, walkways, a lawn and mature shrubs. The home provides day care for several Service Users each day. Day care service is not inspected by CSCI, and so does not form a part of this inspection. However, the Inspector was able to ascertain that additional staffing is deployed if it is needed for additional persons in this category. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over one and half days. The inspectors spoke with both the manager and assistant manager, three members of staff were interviewed in private and a number of staff and residents were spoken with during the course of the inspection. Information they contributed has been incorporated into this report. A number of relatives and GPs completed CSCI comment cards. Staff assisted service users to complete comment cards and these comments have also been included. During the course of the inspection a number of documents and records were examined and the files of four service users were examined specifically relating to their care. Additionally parts of the premises were inspected. Fees for the care and service provided are currently £410.06 to £460.95 for service users assessed as having dementia. There are additional costs for newspapers, hairdressing, chiropodist etc. What the service does well: Service users are provided with a contract, which includes arrangements for the payment of fees, details of the room to be occupied by the service user, and both parties responsibilities. Staff responsible for activities record this information fully in service users’ care plans. Whenever possible service users are able to retain the GP they had in the community. The home operates a key worker system providing additional help and support to service users. Staff spoke to service users in a respectful manner and respect their privacy and dignity. Service users benefit from two full time activity co-ordinators and there is a well-equipped art and craft room. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 6 KCHT have adapted a bus with additional staff which is used as a mobile activity centre and is shared between a number of homes. The policy and procedures regarding making complaints are clear, concise and easy to understand. Sound recruitment procedures were found to be in place. Staff are provided with appropriate and varied training opportunities to help them meet the needs of the service users accommodated. There are quality assurance mechanisms in place. What has improved since the last inspection? What they could do better: At the time of the inspection a number of people were being accommodated outside the home’s terms of registration. Care plans should be completed in more detail. Action must be taken with regards to a number of issues that arose in relation to the recording and administration of medication. Whilst it was evident that service users receive a very nutritious diet, staff were asked to keep a more detailed written record of food provided to service users. Action needs to be taken to provide sufficient privacy screening around both beds and the wash hand basin in the double room. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 7 The current laundry must be updated to comply with Department of Health guidelines. POVA checks must be undertaken as part of the recruitment procedure. At present six members of staff hold a first aid qualification; it is recommended that this number be increased. 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. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 8 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 Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 9 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): 1,3, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with comprehensive information about the care and service in the home. EVIDENCE: This service has a condition of registration which restricts the number and category of service users admitted for short term or respite care to four. At the time of the inspection the manager stated that the home accommodates up to ten people on a respite or short-term basis, which is outside the home’s conditions of registration. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 10 Following on from this inspection the CSCI registration team stated it would be necessary for Kent Community Housing Trust (KCHT) to apply for a major variation to have the existing condition removed and amend the current terms of registration. Additionally one service user who has resided in the home for a number of years is also outside the home category of registration and KCHT need to include this person’s details when applying for the variation. The sample of service users files seen indicated they have been provided with a contract, which includes arrangements for the payment of fees, the room to be occupied by the service user, both partys responsibilities and comprehensive information about the care and service provided in the home. KCHT has recently introduced a new assessment and care plan for service users. All service users are admitted via the local authority and in the first instance information regarding service users’ needs is supplied by care managers. The manager or assistant manager previously undertook service users pre admission assessments; however, KCHT have now employed a peripatetic assessor specifically to undertake pre admission assessments for any service user being admitted to a home managed by them. This is being implemented on a trial basis. In the inspectors opinion the assessment format is basic; however, the acting manager spoke positively of the process and felt overall it had been beneficial. Following the initial assessment a letter is sent to the service user/advocates confirming the home is able to meet their needs. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 11 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. Service users’ care plans need to be completed in more detail to enable staff to meet service users’ needs. Service users’ privacy and dignity is respected by staff working in the home. Medication procedures need to be reviewed to safeguard service users. EVIDENCE: The organisation has recently changed the format of care plans. A sample of four was seen on this occasion. Although key information had been completed there were generally a lot of blank areas. In some instances it may not have been possible to ascertain certain information from service users i.e. their social history; however there were other parts that should have been completed. For example Staff should have recorded moving and handing Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 12 assessments in relation to bathing and none of the sample seen indicated that staff had ascertained service users’ wishes in respect of funeral arrangements. Information in some of the care plans did not provide staff with sufficient guidance to meet service users’ preferences i.e. wakes up fairly early or likes to go to bed early does not provide enough detail for staff to realistically assist service users. Generally daily entries were also vague, for example entries in relation to meals such as good diet light diet ate fair diet does not provide sufficient information to show that service users’ nutritional needs are being met. These issues were discussed with the acting manager who stated that training was currently being arranged for staff to enable them to complete the care plans more comprehensively. It was good to see staff responsible for activities had been recording this information in service users’ care plans. Whenever possible service users are able to retain the GP they had in the community. A number of GPs completed CSCI surveys and stated that staff communicated well with the surgery and they were satisfied with the overall care provided. The district nurse attends service users in the home on a regular basis and service users are able to access more specialised health care professionals as and when required. None of the current service user group has pressure areas at present. The home operates a key worker system; staff spoken with were able to provide the inspector with a clear picture of the additional responsibilities this entails and the way in which they provide help and support to service users they are responsible for. Good interaction was seen between staff and service users. Staff addressed service users by their preferred name, and spoke with them in a respectful manner. A service user spoken with stated staff were very kind. Service users who completed CSCI surveys stated staff listened to them and acted on what they said. A service user spoken with stated she only comes occasionally to have lunch and have her hair done; however, she enjoyed coming and everyone is very nice. Staff were seen to respect the service users’ privacy and dignity when assisting with personal care. Relatives who completed comment cards stated they were satisfied with the overall care provided and felt they were kept informed of important matters concerning service users. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 13 Service users spoken with stated the felt able to make choices about day-today issues such as social activities and what time they wanted to go to bed. The storage, recording and administration of medication was examined. The main storage area for medication is secure and there is adequate space for the preparation and storage of medication. The medication room does not have an effective ventilation system and on the day of the inspection was being cooled by a portable domestic electric fan; this is unlikely to be effective during warmer weather. The responsible person is advised to maintain a log of room temperatures to ascertain if a more effective air conditioning system is required. A number of issues arose in relation to recording and administration of medication. There were instances of gaps on MAR sheets without explanation. One MAR sheet had been amended by staff and although staff stated the GP had asked for a dose of medication to be amended it was not possible for them to find written evidence of this. One service user had just completed a course of antibiotics. The MAR sheet indicated the last dose for the day had been administered at 5pm. Unless other wise directed by the pharmacist the last antibiotic of the day should be administered later in the day to ensure they continue to be effective over night. Medication details for one service user indicated that she has been prescribed medication by a GP to reduce anxiety or agitation. The prescription states 1 or 2 tablets may be given. Although staff had recorded this information, discussion took place regarding how staff who are not medically trained would make the decision as to the correct dose to be administered. Staff were advised to discuss the issue with the GP to ascertain if an alternative medication regime could be implemented to safeguard staff and service users. Medication on the first floor unit is housed in a clinical wall cabinet and locked trolley secured to the wall in the dining room; this detracts from a home like environment. On the day of the inspection one tablet was found lying on the dinning room floor. A service user who completed a CSCI survey stated sometimes medication is late at night and sometimes given out after I have gone to sleep and then I have trouble going back to sleep. The responsible person should review the systems in place regarding the administration of medication at night as part of Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 14 the homes regular audit and take appropriate action to ensure this is not a regular occurrence. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 15 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, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to maintain links with family, friends and the local community. Service users are provided with a varied balanced nutritional diet and varied opportunities to participate in social activities. EVIDENCE: Service users benefit from two full time activity co-ordinators and there is a well equipped art and craft room. KCHT have also adapted a bus with additional staff which is used as a mobile activity centre and is shared between a number of homes managed by KCHT. There is also a shared mini bus and from records seen it is apparent that service users have the opportunity to participate in a number of social events outside the home i.e. a local church coffee morning, garden centre and pubs for lunch etc. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 16 A visitor spoken with in the home and relatives who completed CSCI questionnaires stated that they are always made to feel welcome and are able to meet with service users in private if they wish to. Since the last inspection a room on the first floor has been designated as visitors room. One relative stated that prior to the most recent refurbishment there had been a small satellite kitchen where visitors were able to make light refreshments; this had promoted general social interaction between visitors and service users and was greatly missed. Bedrooms seen were individually personalised with service users’ own possessions, photos and mementos. The home has a designated smoking room. Records seen indicate that service users are provided with a varied and nutritional diet. Discussion took place regarding the need for staff recording information regarding food to more clearly define the choices on offer i.e. entrys such as seasonal vegetables or soup of the day do not give enough information to prevent repetition occurring. Service users who completed CSCI surveys indicated, They usually liked the meals in the home. One service user spoken with stated they could choose an alternative if they did not like the planned options for the day. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 17 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 the service. Service users and their advocates can be confident that appropriate action will be taken to address any concerns raised. Adult protection training is in place to safeguard the wellbeing of service users. EVIDENCE: The policy and procedures regarding making a complaint are clear, concise and easy to understand and all relevant contact details for the organisation and the CSCI are provided. Service users and their advocates are given information about the organisations complaints procedure at the time of admission. One relative who completed a CSCI survey stated when she had raised a concern on behalf of a service user staff had taken action to address the matter promptly. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 18 The CSCI have received no complaints regarding the care or service provided since the last inspection. The majority of service users who completed CSCI surveys stated they were aware of KCHT complaints policy and felt staff listened to what they had to say. Staff spoken with the stated they had received adult protection training and were aware of the term whistleblowing. Staff spoken with stated they felt confident that they could go to senior staff working in the home if they had any concerns regarding the practise of colleagues. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 19 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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Action needs to be taken to ensure service users are accommodated in a clean, comfortable, hygienic environment. EVIDENCE: Communal areas are provided with appropriate seating in a range of styles and heights. Staff have ensured that small tables are provided to enable service users to place cups etc safely. Service users bedrooms seen were individually personalised and people spoken with stated they found their bedrooms comfortable and had everything they required. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 20 One service user who completed a CSCI survey and wished to remain anonymous stated they had lived in a home for a number of years and would like their bedroom to be redecorated. The home still has a double bedroom, although the manager stated this is infrequently shared as it is used as a bedroom for short-term care or if an emergency admission is required. Action needs to be taken to provide sufficient privacy screening around both beds and the wash hand basin. A smell of urine pervaded areas on the top floor and action is required to eradicate this problem. The current laundry is very out dated and must be updated to comply with Department of Health guidelines. The layout of the area means that foul and clean linen are being processed in the same area. Staff who had been working in the laundry had left the door open and cleaning substances that could be potentially hazardous were easily accessible in the area. Staff spoken with responsible for undertaking domestic duties stated they have access to appropriate protective clothing and gloves when required. Additionally appropriate bags are provided for the processing of soiled linen to minimise the risk of spread of infection. The flooring in the staff toilet is substandard and in need of replacement to ensure the area can be effectively cleaned to minimise the risk of the spread of infection. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are in place which safeguard service users. KCHT provide staff with appropriate training opportunities. EVIDENCE: Relatives who completed CSCI surveys were divided in their response regarding staffing levels in the home. Although some felt this was not an issue others felt staffing levels could be improved. One relative felt there was a particular issue with less staff working at weekends; however the manager stated that staffing levels remained the same over the seven-day period. Staff spoken with expressed their concern at trying to meet the needs of service users admitted on a short-term care basis. At present the home is accommodating up to 10 service users on a short-term basis. Staff stated this created difficulties as they needed to spend more time providing guidance and reassurance to new service users and that as a consequence of this long-term service users have their daily routine disrupted. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 22 Staff felt that service users needs would be more appropriately met if there were dedicated staff allocated to service users admitted for short-term care. Relatives expressed the opinion that they found staff to be approachable and helpful. 50 of care staff working in the home have completed an NVQ 2 in care. A sample of four staff files were examined in relation to recruitment. Sound recruitment procedures were found to be in place with evidence that staff had been required to complete application forms, attended formal interviews and provided proof of identity. CRB checks had been undertaken for all members of staff employed. Discussion took place with the acting manager regarding the need for the organisation to provide written evidence that POVA checks had also been undertaken as part of the recruitment procedure. Two of the files examine did not have photographs of the employee attached; the manager stated that this would be addressed in the near future. Three members of staff were interviewed in private and confirmed they receive supervision on a regular basis from a senior member of staff to enable them to discuss practice issues and identify training needs and personal development. Staff stated they had been provided with job descriptions and had a contract indicating their terms and conditions of employment. Staff confirmed that when commencing employment they had an induction period, which included information regarding the organisations policies and procedures and shadowing a senior staff member in relation to practical tasks. From discussion with staff they are provided with appropriate and varied training opportunities to help them meet the needs of the service users accommodated. Staff are provided with statutory training such as food hygiene, health and safety and moving and handling training. In addition since the last inspection staff have received training regarding the care of service users with dementia challenging behaviour. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a system in place for reviewing and improving the quality of care provided. Health and Safety practises and staff training protect service users and staff working in the home. EVIDENCE: The acting manager holds a number of qualifications in care and management and has considerable experience of working with older people. The manager moved from another KCHT home some months ago on a temporary basis and it has now been agreed that she will remain in Homeleigh permanently. The Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 24 manager stated that she has obtained the relevant documentation from the CSCI to complete an application to be the registered manager of the home. Staff spoke with stated they have regular meetings and feel able to voice their opinions. One member of staff expressed the opinion that she enjoyed working in the home very much and felt staff worked as a team. The manager stated she undertakes her own audit of the care and service provided and provides regular reports to her line manager in accordance with Regulation 24 of the Care Home Regulation 2002. KCHT ensure a monthly audit is undertaken in accordance with regulation 26 of the Care Standards Act 2000. A copy of this report is forwarded to the CSCI. Records seen indicate that a number of service users are unable to manage their finances independently; in these instances they are assisted by relatives or a local authority financial advocate who acts on their behalf. Small amounts of money are retained for individually named service users. The sample examined indicated that service users personal allowance tallied with the house records. Relatives are provided with a receipt when depositing money on behalf of service users and a record is kept of money deposited and withdrawn. The administrator assists one service user by writing cheques for the service user to sign as and when she requires, the administrator was advised to have another member of staff witness the process to safeguard herself. Service users finances are further safeguarded by the fact that KCHT ensure that a formal audit is undertaken on an annual basis. Information provided at the time of the inspection indicates that there are regular safety and maintenance checks undertaken in relation to hoists used in the home, lifts, gas and electrical appliances. Records seen indicate that there are regular checks to the fire detection system within the home and staff are provided with regular fire safety training. There is a weekly check to the fire alarm system Staff are provided with appropriate health and safety training. At present six members of staff hold a first aid qualification; it is recommended that this number be increased. Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 25 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 3 X 3 X 3 3 X 3 Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 26 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 15(b) Requirement The registered person must ensure service users care plans are complete with up-to-date information. The provider must apply to the CSCI for a variation of registration for the service user accommodated outside of the home category of registration and for the homes current condition of registration to be amended. The register person must take action to eradicate the smell of urine apparent on the top floor. The registered person must take action to make suitable arrangements to prevent the spread of infection, in this instance up grade the laundry to meet the requirements of The Department of Health. An application must be made by the manager to be registered with the CSCI. The responsible person must take action to ensure that medication is safely stored and administered DS0000006793.V307690.R01.S.doc Timescale for action 30/04/07 2 OP1 CSA 2000 15 30/04/07 3 4 OP19 OP26 16(2)(k) 13(3) 30/03/07 30/06/07 5 6 OP31 OP9 CSA 2000 (11) 13 02/04/07 30/03/07 Homeleigh Version 5.2 Page 27 7 OP38 13(4) The responsible person must take action to ensure that hazardous substances are kept secure at all times. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations Provide written evidence that POVA checks are made as part of the recruitment process. 2 3 4 OP9 OP15 OP27 Staff should monitor the temperature of the room where medication is stored to ensure the temperature does not exceed 25 centigrade. Maintain an accurate record of food provided to service users. It is recommended that a review of staffing take place to look at how the additional needs of service users living in the home for a short while can be met. A second member of staff should act as a witness when the administrator writes cheques for a service user to sign. 5 OP35 Homeleigh DS0000006793.V307690.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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