Inspection on 30/11/06 for Lewis W Hammerson Memorial Home

This inspection was carried out on 30th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lewis W Hammerson Memorial Home 10/11/08

Lewis W Hammerson Memorial Home 12/01/06

Lewis W Hammerson Memorial Home 06/07/05

Lewis W Hammerson Memorial Home 01/02/05

Lewis W Hammerson Memorial Home 21/09/04

Lewis W Hammerson Memorial Home 11/12/03

Lewis W Hammerson Memorial Home 21/07/03

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

CARE HOMES FOR OLDER PEOPLE Lewis W Hammerson Memorial Home 50a The Bishops Avenue East Finchley London N2 0BE Lead Inspector Tola Akinde-Hummel Key Unannounced Inspection 10:00 30th November 2006 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 Lewis W Hammerson Memorial Home DS0000010430.V303379.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. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lewis W Hammerson Memorial Home Address 50a The Bishops Avenue East Finchley London N2 0BE 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) 020 8458 4523 020 8458 2537 Lewis W Hammerson Memorial Home Mrs Celia Collier-Bawden Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 68 adults of either gender over the age of 65 years, 15 of whom have nursing needs. 12th January 2006 Date of last inspection Brief Description of the Service: Hammerson House Memorial Home is registered to care for up to sixty eight people over the age of sixty five who are Jewish. The home is owned and operated by a charitable trust on behalf of the Hammerson family and has been registered since 1985. The home is situated in a residential area of North London and is served by public transport. The home is decorated to a high standard and well maintained. There are three floors, with the nursing unit on the ground floor. There is a lift to all floors. There are twenty- two sheltered housing units within the home and these are integrated within the residential home. The home has its own physiotherapy facilities and is run by qualified staff. The kitchen facilities have been contracted to a company who also provide serving staff in the dining room. The aims of the home are That all service users shall live in a safe and clean environment and be treated with respect and sensitivity to their individual needs and abilities. Staff are responsive to the individual needs of service users and will provide the appropriate degree of care to ensure the highest possible quality of life within the home. The current cost of a weekly nursing and residential placements are between £825-£950.00 Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took approximately six hours to complete. The chief executive Mr Andrew Leigh and the Matron Ms Celia Collier- Bawden were available throughout the inspection. The inspector was able to speak in detail to five service users and one relative and more briefly to five service users. The inspector also spoke to a staff group of 14 Nurses and Care staff, the manager of housekeeping and the assistant manager, and the maintenance manager. On this occasion the inspector did not receive any comment cards. The inspector received detailed information from the home on the pre inspection questionnaire and received additional information from the home on the day of inspection. The inspector completed a tour of the building, sampled five service users plans, and sampled some of the homes key policies and procedures such as adult protection, Control of substances hazardous to health and whistleblowing. The inspector also looked at the personnel files of six staff members and looked at the homes maintenance records. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The inspector would like to thank all service users, relatives and staff for their assistance throughout the inspection. What the service does well: Hammerson House provides a comfortable, safe and stimulating environment for service users. Service users are provided with residential care contracts and the service users guide, which provide full information about what they can expect from the home and the homes fees. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 6 Service users needs are assessed prior to entering the home to ensure that any offer of a place in the home is appropriate. Service users like the home and feel well supported by staff. One service user told the inspector, “We are very lucky to be here” another service user added, “ I love it here.” Service users and relatives find the staff approachable and are aware of how to make a complaint and are confident that their issues will be addressed swiftly. The housekeeping team takes great pride in their efforts to maintain a clean and hygienic environment. The management team are proactive in improving facilities provided to service users. An example of this is the increased security in and around the home, which enables service users to feel safer. The home has also purchased pendant alarms for use in the garden connected to the nurse call system. This promotes independence and service user safety. This is to be commended. The management team is well supported by Friends of Hammerson and the management committee. Service users cultural religious and social needs are addressed. The home monitors all activities to ensure they meet the needs of service users. What has improved since the last inspection? Eleven requirements were made at the previous inspection. Nine of these requirements have been met. The service user plans are now reviewed on a regular basis and the weight of service users is adequately recorded monthly. The personnel files of staff have (where relevant) up to date pin numbers and work permits. Recent photograph ID for staff has been addressed and all volunteers have a valid criminal records bureau check. The home doorways and fire alarms identified at the previous inspection are free from obstruction. The food storage issues identified at the previous inspection have been addressed. The above improvements directly affect the health safety and welfare of service users in the home. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 7 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. Lewis W Hammerson Memorial Home DS0000010430.V303379.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 Lewis W Hammerson Memorial Home DS0000010430.V303379.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 Quality in this outcome area is good. This judgement has been made both before and during a visit to this service. Service users can be confident that the home provides all the information required to make an informed decision about the choice of home, information relating to fees and the contract that is entered into. Service users needs are properly assessed prior to admission ensuring that the home is able to meet their needs. EVIDENCE: The inspector was able to speak to five service users who each confirmed that they had received a copy of the service users guide on or prior to admission. All service users confirmed that they are made aware of any changes to the cost of their care and in fact they had all received a letter in the last week outlining the change in the cost of their care that will come into effect in January 2007. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 10 All service users spoken to confirmed that they had received a copy of their contract. On discussion with Mr Andrew Leigh, the inspector was advised that the current contract is with a solicitor with a view to amending the contract for new service users. Five care plans were sampled during this inspection. All plans had preassessment information completed prior to service users entering the home. The relevant placing authority completes these. The home also completes it’s own assessment detailing service users needs. The quality of these assessments is inconsistent depending on which member of staff completes them. There have been ten new admissions to the home in the last 10 months. The inspector was able to speak to five service users who claimed that they or their relatives had visited the home prior to an offer of a placement being made. One service users stated, “ I used to do voluntary work and knew that when I was unable to care for myself this is where I wanted to be”. Lewis W Hammerson Memorial Home DS0000010430.V303379.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 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 both before and during a visit to this service. Service users have care plans that identify their difficulties and these are supported. However for the benefit of a holistic assessment and clear audit trail, care plans must be explicit about what aspects of their care service users are able to manage and document when this is no longer possible to ensure extra support ids provided appropriately. Service users continue to have access to a range of primary health care and specialist health services in the community. The dignity and privacy of service users is upheld at all times. EVIDENCE: Five service users plans were sampled. The inspector looked at the multidisciplinary assessments completed by the home. Two of these assessments were not signed by the person completing the assessment. One of them had very basic information. Improvement of these assessments was a requirement from the previous inspection. The inspector found that the plans highlighted only areas that are identified as problems with little information on how service users manage other aspects of their care and how they are supported to do so. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 12 This does not create a satisfactory audit trail when the situation changes and additional support is needed. In effect a holistic person centred plan is not evidenced. Whilst this is an omission, care plans do demonstrate where support is needed and how this will be provided. The previous inspection required that all plans be reviewed on a monthly basis. These are being done and this requirement is assessed as met. The inspector was also able to examine weight charts and these are undertaken on a monthly basis and more regularly where required, this requirement is also assessed as met. Hammerson House maintains records of all appointments attended by service users in the plans. Records of GP visits are also recorded. On the day of inspection the GP had just completed his weekly visit to service users in the home. District Nurses also visit weekly. Service users are able to make use of local primary health care facilities. Where required, staff escort service users to their appointments. The home also has in house physiotherapy. Four service users spoken to at the time of inspection advised that they are very well supported in the home. On this occasion the inspector did not examine the medication procedures in the home. This will be completed at a later date by one of The Commissions pharmacy inspectors and will be supplementary to this report. However the Matron did not report any difficulties with the storage, administration, recording or disposal of medication. The inspector observed staff respecting the privacy of service users when entering their rooms and escorting then to the toilet. All service users spoken to are addressed by the name they prefer and make choices about what they wear and how they spend their time whilst in the home. Service users confirmed that the staff treat them in a dignified respectful manner. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 excellent. This judgement has been made from evidence gathered both before and during a visit to this service. Service users cultural and religious needs are well met. Service users have a range of activities to choose from that are both stimulating and relaxing. Service users exercise a great degree of choice in the home. The home strives to ensure that food is both appealing and tasty. EVIDENCE: The inspector spoke to five service users in detail and an additional four service users briefly. All service users stated that they are well stimulated by activities within and outside of the home. The home has an excellent art room and on the day of inspection some service users were working on watercolours. The art area has a cabinet where service users decide the theme for the cabinet. Presently some service users have displayed their wedding photographs and invitations. One service user said, “I love coming down here the teacher is fantastic.” Other service users advised, “We are over run with activities and interesting things to do.” The home provides a volunteer to read the newspaper to those with poor eyesight, have current affairs discussions, musicians come to the home to entertain, trips out recently include The London Eye, Theatre shows, and a River cruise. Another service user described the activities as “delightful.” The home has recently employed an activities Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 14 administrator and has purchased computers for service users to use. They will also be given training sessions in their use to enable them to maintain contact with relatives. This was introduced as a result of a survey carried out by the home. Hammerson House provides care for Jewish People. All service users are able to embrace their culture and religion. This is understood and respected by nonJewish care staff. Service users are able to make a wide variety of choices in the home and are able to come in and out of the home at their leisure as long as they sign out and staff have an idea about how long they will be away from the home. The home has introduced extra security by employing a security /receptionist person to further ensure the safety of service user in the building and minimise any risk of intruders. When discussed with service users this was considered a positive step. Service users advised that they and their relatives were consulted about this. The inspector observed that relatives come and go freely in the home and are catered for if they wish to have a meal with their family. The quality of the food continues to have a varied response. On the whole service users think that the meals are ok there are some good and bad days. This is regularly addressed in the monthly catering meetings where service users views are represented. The service users state that the dining room is a pleasant place to eat and they are always provided with clean and fresh table linen. An inspection of the kitchen found food storage to be satisfactory. There is a good supply of fresh fruit and vegetables on offer. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 both before and during a visit to this service. Service users can remain confident that their complaints will be taken seriously and where possible will be satisfactorily resolved. The home ensures that staff are aware of all forms of abuse and understand their responsibility to keep service users safe at all times. EVIDENCE: The inspector spoke to five service users and one relative about the complaints procedure. All service users are familiar with this and know how to make a complaint. Service users added that they would approach Matron in the first instance and she would do what she can to resolve a complaint swiftly. None of the service users had any outstanding issues. Service users also clarified that the procedure for complaining is detailed in their welcome pack, which they received upon arrival or prior to entering the home. There have been 3 complaints since the previous inspection all have been resolved within the homes stated timescale. The inspector was able to speak to 13 staff in a group. Staff were able to explain the process for alerting matron if there are adult protection concerns in relation to service users. Staff have completed adult protection training and many have completed NVQ level two training, which covers all aspects of abuse. The homes abuse policy, which was revised in 2005, has been reviewed in July 2006. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 16 The home has experienced an intruder since the previous inspection. A decision was made to review security and added security measures have been put in place to ensure the protection of service users. The home now has updated and increased its CCTV equipment and has security patrolling the grounds. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,26 Quality in this outcome area is excellent. This judgement has been made both before and during a visit to this service. Hammerson House continuously improves the home environment for service users. This ensures that service users live in a clean, secure and comfortable environment. Service users safety is of paramount importance to the home and the home continually look at ways to promote the safety and independence of service users in their care. EVIDENCE: Hammerson House have a proactive maintenance team that ensures the home is in a good state of repair. The home has recently redecorated the dining area on the ground floor and replaced the windows with shatterproof glass. All ground floor corridors have been repainted and new door numbers added that are easier to read and better quality. The exterior of the building has been repainted as part of the five year rolling programme. The home is about to undertake a survey of all windows with a view to improving them. The emergency lighting on the ground floor has been increased and carpets have been replaced. These improvements are noticeable and makes for a more Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 18 pleasant living environment for service users. The inspector noted that service users are happy with the redecoration. On the day of the inspection first floor rooms were being fitted with fire door closures that work on a sensor and are unobtrusive. The inspector was able to see this at work. This allows service users who prefer to have their bedroom doors open the ability to do so without a door- stop. The sensors are connected to the fire alarm system and will close automatically should the alarm sound. The home has now introduced garden alarms to allow service users the freedom to use the grounds but also call for help should the need arise. These alarms are connected to the nurse call bell so staff will know that their attention is needed outside. The inspector considers this to be an excellent, practical idea that empowers service users that would otherwise feel restricted, from enjoying the outdoors. The home has an excellent Housekeeping team that ensures all areas of the home are kept clean and free of odours. The team is now fully staffed and the manager has employed an assistant who helps to manage the domestic staff. Service users advised the inspector that their rooms are kept spotless and when asked staff will turn the mattress. All service users spoken to were complimentary of the housekeeping team and their management of the laundry. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 good. This judgement has been made both before and during a visit to this service. The home ensures that all staff are competent to carry out their tasks in a caring and professional manner. The homes recruitment procedure ensures that service users are properly vetted prior to working in the home. EVIDENCE: The inspector was able to meet with a group of fourteen members of staff following their handover session. New staff advised that they were being shadowed by more experienced staff during care tasks to make sure they are providing appropriate assistance. The majority of care staff have completed their NVQ level 2. The home has two NVQ assessors available. The home also has a permanent in house Moving and Handling trainer. All staff receives the GSCC handbook and in addition the Hammerson House staff handbook. Employees sign for these on receipt. When asked about staffing levels the inspector was advised that there is enough staff available to support service users and where there is extra pressure due to increased needs of service users, staffing is increased to meet the need. Nurses in the home stated that they have received training recently in managing depression in the elderly. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 20 Some staff indicated that they would benefit from more training especially around taking temperatures and blood pressure monitoring. When discussed with the Matron it was acknowledged that additional staff training was an area to further explore. The home would benefit from undertaking a training needs analysis to assist with exploring any gaps in the training for staff. Staff also advised that they work with the tissue viability nurse and refer service users to the falls clinic where there are issues around falls and mobility. Staff cited their reasons for working in the home as: the good standard of care offered to service users, team work, the cleanliness of the home and the dedication and competency of the matron. The inspector looked at the recruitment records of six members of staff. The process of recruitment is robust. The previous requirement to ensure that Nursing staff have current PIN numbers recorded on personnel files and that photograph ID is on personnel files has been met. The requirement to ensure that all volunteers have a valid criminal records bureau check has also been met. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected 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 good. This judgement has been made both before and during a visit to this service. Hammerson House protect the Health Safety and Welfare of service users staff and visitors to the home by maintaining safe working practices. All Heads of departments in the home are competent to do their jobs and work effectively as a team for the benefit of service users. The system for safekeeping service users monies is robust with clear accountability. Supervisions of staff require more attention and the home is aware of this. EVIDENCE: The home is managed by the Matron Ms Celia Collier Bawden and run by Mr Andrew Leigh, Chief Executive. The Matron and the Chief executive work very well as a team looking at practice issues and the overall running of the home. This partnership is clearly reflected in the success and quality of the services provided in the home. The Matron who is a qualified nurse, has worked in the Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 22 home for over 15 years, is extremely hard working and conscientious, expecting high standards from the staff team and herself. All heads of departments meet regularly to ensure a good overall service is provided. The home routinely elicits the views of service users and their relatives. This is done within residents and relatives meetings and also through questionnaires. This was done recently in relation to the additional security measures that were put in place and the introduction of computer training for service users. Service users have access to their finances when required. The home has a robust system for managing some service users money. The recording of all transactions is satisfactory. The home does not act as appointee for any service users. Relatives and friends also assist Service users. Approximately 16 service users manage their own finances. The previous inspection identified that supervisions of staff were not taking place at regular intervals. The home has tried to address this, however due to staff sickness and the lack of an assistant Matron as was planned, this has lapsed. The home has tried to address this by organising group supervisions. This will continue until one to one supervisions can be arranged. However the Matron is mindful that this is an area for improvement. On discussion at the inspection, the Matron will ensure that these supervisions are attached to handover to ensure that any issues raised by staff can be immediately addressed and staff will have the option of individual supervision if required. The Health, Safety and Welfare of service users are properly considered by the home. The inspector met with the Head of Maintenance and was able to view the homes records, which confirm that all the necessary fire drills and checks are undertaken regularly. Following a fire drill in the home a week before the inspection, it was identified that there is a mechanical fault in one part of the system. This is being investigated and will be addressed. Staff are aware of the fire safety procedures. Service users confirmed that fire alarm testing takes place regularly. During a tour of the building the inspector found that all fire alarms and hallways were free from obstruction as required at the previous inspection. All equipment is serviced, electrical appliances and equipment are regularly tested and all remedial work necessary is undertaken. Room water temperatures are undertaken on a monthly basis and the water is chlorinated and showers cleaned four times per year. All lifts are serviced monthly. The inspector completed a tour of the kitchen area and found this to be in satisfactory condition. The storage of food is properly undertaken as required at the previous inspection and the equipment used in food preparation is clean, two bins in the kitchen require updating. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 23 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X X X X 4 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 4 X 3 X 3 2 X 3 Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 24 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 14, (1), (a), 2 (a) Requirement The registered person must ensure that multi- disciplinary assessments are completed for service users entering the home. Staff must sign these. (Previous timescale 28/02/06 not met) The registered person must ensure that the service users plan is holistic, addressing all areas of service users abilities and needs and that this is kept under review. The registered person must ensure that all staff receives supervision at least six times per year. (Previous timescale 29/12/06 not met) Timescale for action 12/01/07 2. OP7 14, (1), (a), 2 (a) 23/02/07 3. OP36 18, (2) 12/01/07 Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 25 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. 2. Refer to Standard OP33 OP30 Good Practice Recommendations The chief executive with the matron should consider sampling care plans as part of the quality assurance process. The matron should consider undertaking a training needs analysis of all staff to identify where there are gaps in training. Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lewis W Hammerson Memorial Home DS0000010430.V303379.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!