Inspection on 04/11/08 for Homeleigh

This inspection was carried out on 4th November 2008.

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

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

Homeleigh 21/09/09

Homeleigh 07/11/07

Homeleigh 10/01/07

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Homeleigh Avenue Road Erith Kent DA8 3AU Lead Inspector Lorraine Pumford Unannounced Inspection 4th November 2008 & 23rd December 2008 09:30 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.V374047.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.V374047.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 susan.ilott@kcht.org.uk www.kcht.org Kent Community Housing Trust Susan Jacqueline Ilott 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.V374047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 32) Dementia - Code DE(E) (of the following age range: over 65 years) (maximum number of places: 16) The maximum number of service users who can be accommodated is: 48 7th November 2007 2. 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 three form the care home. There are bedrooms, bathrooms and toilets on each floor. There are a number of lounges, a dinning room and activity room on the ground floor. 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 up to five people each day. This service is not inspected by CSCI, however the impact on other people living in the home is taken into consideration. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place over two days. We met with the people who live in the home, the manager and staff on duty. In addition surveys were sent to staff, residents advocates and health care professionals that meet with people living and working in the home and some of their comments have been included in this report. We looked at the Annual Quality Assurance Assessment, AQAA, sent in by the provider. This self-assessment document focused on the outcomes for people using the service and plans the provider is making for the future operation of the service over the forth-coming months. The last inspection report was viewed. We looked at what the provider had told us about events that have happened in the service, these are called notifications and are a legal requirement. During the time we spent at the home we examined a number of policies, procedures and documents and undertook a tour of the buildings. Fees range from £441.42 to £545. What the service does well: Information about the service is made available to prospective residents and people benefit from being able to view the home and facilities before moving in. People have their needs assessed prior to moving in to the home. People living in the home have opportunities to participate in a wide range of appropriate activities. Residents benefit from a varied nutritious diet. Residents are supported to maintain links with family and friends. People living in the home benefit from a clear complaints procedure and can be assured that any concerns they have will be taken seriously. Adult protection training for staff helps safeguard people living in the home. People living in the home benefit from staff being provided with appropriate training to undertake the work they need to perform. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 6 People living in the home spoke highly of staff and the care they provide. Sound recruitment procedures help safeguard people living in the home. What has improved since the last inspection? What they could do better: Care plans must be completed in more detail to provide staff with guidance to meet peoples needs. In general residents privacy and dignity is respected however all staff must respond promptly to residents asking for assistance. Medication procedures have improved however further action is required particularly with regards to medication storage. Night staff must be included in fire drills. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 7 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.V374047.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.V374047.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): Standard 1,3.The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff undertake a care needs assessment before confirming if the home would be able to meet people’s needs. Information about the service is made available to prospective residents and people benefit from being able to view the home and facilities before moving in. EVIDENCE: People who completed surveys were satisfied with the information that they received about the home. A requirement made at the time of the last inspection regarding the need for Statement of Purpose to be updated to reflect that the home also provides day-care for people. The manager stated the action had been taken to address this. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 10 Pre admission assessments are undertaken by the providers Assessment Officer. Assessments were seen for two people admitted to the home since the last inspection. Information is obtained from the prospective resident and other people that are involved in their care, such as care managers, relatives and health care professionals. The assessments that we looked at provided information about the persons physical, mental and social care needs. Homeleigh DS0000006793.V374047.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home would benefit from care plans being completed in more detail. In general residents privacy and dignity is respected however, all staff must respond promptly to residents asking for assistance. Medication procedures have improved however further action is still required particularly with regards to medication storage. EVIDENCE: A requirement was made at the time of the last inspection with regards to information provided in care plans. The provider has recently changed its care plan format and staff have been moving from the old system to the new one. We looked at the complete care plans for two residents under the new format and parts of care plans for three other people in relation to activities and health. The level of detail varied between the plans, one provided good detailed information for example by stating what the person was able to do in relation to their own personal care and the aspects of the persons personal care they Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 12 would require a staff member to undertake. However other care plans examined provided staff with little guidance on action required by them to assist the person. For example in relation to the persons mobility one stated, I need assistance to mobilise and transfer and another mobility poor needs assistance, walking frame which is insufficient information for staff to support residents. Unfortunately all the care plans seen had parts incomplete, for example in one instance nutritional, emotional and continence had all been left blank, so it was not possible to know if the document had not been completed correctly or staff thought the person did not require any care and support in these areas. Documents were not signed by a member of staff although it was good to see in two instances the resident had signed their care plan. The sample of care plan seen were discussed with the manager and Assistant General Manager. Although none of the sample seen included dates for the care plan to be reviewed, people that completed surveys stated they were kept informed of important events effecting the health and well being of their relative living in the home. A requirement was made at the time of the last inspection that a system must be in place to monitor all resident’s weight for the purpose of monitoring residents’ nutritional needs. The manager stated that people are now routinely weighed as part of the admission process if this raises any cause for concern the persons GP is informed and the nutritional needs assessment is completed in the person care plan. When sitting in the ground floor dinning room talking to some residents a person called out to a member of staff who was handing out morning refreshments they needed to go to the toilet. The member of staff did not acknowledge the person and carried on with handing out drinks. We went to find another member of staff to assist, two members of staff were having a morning break and the team leader was processing medication. There were no other members of staff on the floor and the person waited over ten minutes for a member of staff to assist them. This matter was discussed with the manager who stated the matter would be discussed with the staff member concerned. In general people who completed surveys stated the felt staff listen to them and staff are usually available when needed. Staff were seen to address residents in a respectful manner. Particularly good practise was seen on the unit which provides care for people with dementia; staff here was supporting residents in a calm unrushed manner and were seen to provide reassurance to people who were becoming anxious and unsettled during lunchtime. Documents seen indicate that a record is kept of residents health care appointments. Residents are able to keep their existing GP, if the GP is willing to visit the home should they become unwell. Residents spoken with and Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 13 people who completed surveys were satisfied with the medical support they received in the home. A requirement was made at the time of the last inspection regarding staff practise in relation to medication. Although some progress had been made further action is still required. Three months of records were seen in relation to the temperature of the room where medication is stored. This indicates that the temperature of the room is regularly higher than the 25 degrees centigrade recommended, although there is a portable electric fan situated in the room a more effective system must be installed. A medication and administration record sheet had been amended and the dose of paracetamol changed from two to one however there was no record of who or why this had been changed. Pain relief patches for one person were found in the medication trolley however directions for storage state these should be kept in the medicine fridge. We talked to a member of staff about the training they had undertaken before being permitted to administer medication. Staff stated they attended formal training at a local college, the course had been comprehensive and a competence assessment has to be completed before people are able to undertake the task independently. A nurse who visits people living in the home said she was satisfied that the health and care needs of people living in the home were met. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have opportunities to participate in activities and benefit from a varied nutritious diet. Residents are supported to maintain links with family and friends. EVIDENCE: The home has its own designated activity coordinator who arranges activities throughout the week. There is a large well-equipped room used for activities and on the day we visited people participating in arts and crafts. The manager stated that in addition to the annual Christmas festivities residents have recently enjoyed a visit from a country and western singer and a small group of residents enjoyed attending a Barry Manilow concert in Greenwich. A small group of residents also enjoyed a holiday earlier in the year. On the first day we visited the home we were able to meet two members of staff who operate KCHT Bright Days . This is an activity scheme all of the homes operated by KCHT benefit from. The teams take residents on visits to local garden centres, parks, shops and places of interest and also undertake Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 15 small group activities. On the day we visited people who live on the first floor unit were being supported to participate in a craft activities. People spoken with and relatives who completed surveys stated they were satisfied with the activities provided. At the time of the last inspection relatives voiced concern to us that they had difficulty contacting people in the home by telephone outside office hours as the telephone could only be heard by staff working in the immediate area. A new telephone system had been installed and this is no longer a problem. Resident advocates who completed surveys stated they were made to feel welcome when visiting people living in the home. One person told us that staff helped her to keep in touch with her relative who lives in the home by telephone. A requirement was made at the time of the last inspection regarding the need for residents to be consulted about people attending the home for day care. In addition to amending the home Statement of Purpose records seen indicate that the matter was discussed with people at a residents meetings. Residents we spoke with stated they felt settled and comfortable in the home and felt able to make decisions about how they spent their time. Peoples bedrooms are all individually personalised with photographs and personal mementos. We spoke to some people living in the home about meals and looked at comments made in surveys sent to us. Everybody stated they enjoyed or usually enjoyed meals provided. Records seen indicate that people are provided with a varied nutritional diet. We observed lunch being served on the second floor unit. Tables were appropriately laid and a choice of juice was available. Unfortunately some confusion arose in that the food brought to the unit for lunch did not tally with that on the menu however fortunately staff knew residents likes and dislikes and discussed with residents their preferences in relation to the meal that had been provided instead of that written. Rice pudding was provided for desert and a member of staff went to the kitchen for jam to help make it more appetising for residents. One person was in bed unwell and a staff member was preparing the persons favourite light snack to help encourage them to eat. Staff offered support and encouragement to people who required assistance with eating. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from there being a clear complaints procedure and can be assured that any concerns they have will be taken seriously and addressed promptly. Adult protection training for staff helps safeguard people living in the home. EVIDENCE: The home has a clear complaints procedure. Information provided in the AQQA indicated that they have been four complaints made in relation to the home since the last inspection. All complaints were recorded in the complaints logbook and the manager completes a monthly report which is sent to head office. We looked at the records in relation to the action taken by the manager to address concerns brought to her attention and records showed that complaints were investigated and responded to promptly. All of the people who completed surveys stated they were aware of the complaints procedure and people said they would speak to their relatives or specific staff members if they had concerns. One person said that when they had raised concerns previously they had been dealt with promptly and to their satisfaction. Staff were aware that they must report allegations or concerns to senior staff or the manager. Training records showed that almost all of the staff had Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 17 attended a protection of vulnerable adults training session and the manager stated that regular training updates are provided. The manager notifies us about significant events that occur in the home and seeks advice from other agencies such as social services. Since the last inspection four incidents have occurred within the home which have been referred to social services to be investigated under the joint working safeguarding adults protocol. From discussion with the manager is apparent that action has been taken to help prevent an incident from reoccurring. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in the home benefit from living in a clean comfortable environment. EVIDENCE: Homeleigh is a large purpose-built home; although overall the building is large staff have taken steps to make the building more homely by displaying lots of pictures and photos and arranging small seating areas in some corridor areas. Residents accommodation is spread over three floors. The ground floor consists of office space, some bedrooms and toilets, a large dining room, a room used for activities and a small room, which is the designated smoking room. Also situated on the ground floor are three lounges giving people a choice of where they prefer to sit, the clinical room and staff room. There is a smaller unit on the second floor with a self-contained kitchen dining area and lounge which accommodates people who have been assessed as having dementia. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 19 The home is situated on the side of a hill and therefore it is possible for people living in this unit to directly access a small garden area to the rear of the building. None of the people we spoke with who completed surveys raised any issues or concerns in relation to the building. One person wrote although the home is not the most modern, the staff are very kind and that is more important Information provided in the AQQA indicates that a programme of redecoration has taken place since the last inspection. A requirement was made at that time that dirty seals around wash hand basins should be replaced an action has been taken to address this. A requirement was made at the time of the last inspection that a room should be made available for day-care people to rest if they become unwell during their visit to the home. The manager stated that it was not possible to set aside a room specifically for this purpose however a vacant bedroom is always available and is set aside for this purpose. A requirement was made at the time of the last inspection that the emergency lighting on the second floor should be repaired and action has been taken to address this. On the day that we visited we found all areas of the home clean and free from unpleasant odour. The laundry area was clean and organised. Staff stated that the equipment meets the current needs of the residents accommodated. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from staff being provided with appropriate training to undertake the work they need to perform. Sound recruitment procedures help safeguard people living in the home. EVIDENCE: In addition to a manager, two assistant managers and care staff there are designated staff who arrange activities, undertake administrative tasks, cooking, cleaning and maintenance. One relative who completed a survey raised concerns about staffing at the weekends stating that there was not enough permanent staff and the home relied on agency staff who although willing and friendly did not have a good understanding of individual residents needs. Interviews to fill care staff vacancies were taking place during our first visit, the manager stated they were still waiting to receive a CRB clearance before new staff could commence work, and this will reduce the need to use agency staff. Two requirements were made at the time of the last inspection in relation to staff recruitment and training and it was apparent from discussion with the manager and records seen that action has been taken to address these. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 21 We looked at staff files for three people who have been recruited to work in the home since the last inspection. Staff files were up to date and orderly, making it easy to locate information. The files included proof of identification, an enhanced criminal record bureau disclosure, interview notes, proof of qualifications and training and information about the employees physical and mental health. There was evidence that written references had been taken up on people employed. One person was still on probation and the manager stated that the person worked under direct supervision of a senior member staff until their first review. The manager stated that the provider has a system in place to routinely update employees CRB checks. More than 70 of people working in the home hold an NVQ 2 qualification in care. Some members of staff had attended fire safety, moving and handling, food safety, health and safety, infection control, medication, bedrail, COSHH, safeguarding, dementia, customer care and mental capacity act training sessions since the last inspection. Staff were satisfied with the training arrangements. The manager and care staff explained that staff team meetings take place on a regular basis. The record of these meetings was inspected and it could be seen that they discuss a range of operational issues. Records seen also show that people working in the home have regular supervision and appraisals. One person who completed a survey summed up how they felt by saying, they listen, they help, they act, and they care. Another person stated all staff are sympathetic to peoples needs. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living and working in the home benefit from a home that is well managed. The atmosphere in the home is open and friendly. Night staff must be included in fire drills. There are systems in place to monitor and improve the quality of care provided and to safeguard people’s money and to maintain safety standards. EVIDENCE: The manager has a number of years experience of running a care home and holds relevant qualifications. The home has various systems in place for monitoring the quality of care and services provided and for obtaining feedback from residents and relatives. The provider ensures that a monthly audit is undertaken to monitor the care and Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 23 service in the home. In addition some other audits are carried out by outside agencies and Kent Community Housing Trust has been awarded an Investors in People Award. A requirement was made at the time of the last inspection regarding the need to keep a record of any valuables held by the home for safekeeping and action has been taken to address this. Individual records are kept in relation to money debited and credited to peoples accounts. Receipts are kept for items purchased for people or for services that are provided such as the hairdresser. Money and valuables are stored securely. Health and safety records were sampled and were found to be well organised and up to date. We looked at fire safety reports, this included the fire alarm, fire extinguishers and emergency lighting service reports and internals checks such as weekly fire alarm tests, fire door tests, emergency lighting tests and fire safety training records. We looked at the record in relation to fire drills and discussion took place around the need for night staff to be included in this form of training and action must be taken to address this. Health and safety issues were well managed. Equipment such as hoists and passenger lifts are serviced regularly. Hot water temperatures are tested regularly. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 3 X X X X X X 3 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 X X 2 Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(b) Requirement Timescale for action 30/04/09 2. OP9 13 3 OP10 12 3 OP38 18 The registered person must ensure residents care plans are complete with up-to-date information. Timescale 30/04/07, 03/03/08 not met. The registered person must 30/04/09 ensure that all medication is stored, recorded and administered in line with the Royal Pharmaceutical Society guidelines. Medication must be appropriately stored and kept at the required temperature. The registered person must 09/02/09 ensure that all staff understand the need to respond promptly to residents asking for assistance to safeguard residents dignity. The registered person must 28/02/09 ensure that all staff working in the home have the opportunity to participate in fire drills. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations Staff should sign care plans they are responsible for completing. Homeleigh DS0000006793.V374047.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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