Inspection on 01/06/06 for Limegrove

This inspection was carried out on 1st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Limegrove 11/09/06

Limegrove 07/11/05

Limegrove 19/04/05

Limegrove 12/10/04

Limegrove 18/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Limegrove Limegrove St Martin`s Close East Horsley Surrey KT24 6SU Lead Inspector Sandra Holland Unannounced Inspection 1st June 2006 12:30 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 Limegrove DS0000033691.V295485.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. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limegrove Address Limegrove St Martin`s Close East Horsley Surrey KT24 6SU 01483 280690 01483 280834 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) sharon.blackwell@anchor.org Anchor Trust Mrs Christine Maureen Conroy Care Home 54 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (13) Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: Limegrove is a large purpose built home for older people located in the village of East Horsley. The home is registered to provide personal care and support for up to 54 service users. The home is divided into five self contained units each with their own lounge, dining room, kitchenette, toilets and assisted bathrooms. All residents bedrooms are for single occupancy with an en-suite facility. A meeting room is available and is used for some resident activities. Other activities are carried out on the individual units. The home has spacious, well-maintained gardens and is located close to the local village, with its shops and church. There is parking to the front and rear of the property. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007. AS it was unannounced, no-one at the home knew it was to take place. Mrs Sandra Holland, Lead Inspector for the service carried out the inspection over seven and a quarter hours. Mr Jason Creed, Deputy Manager and Mrs Ann Wilson, Senior Carer were present representing the service. A number of records and documents were examined including individual plans of care, medication administration record (MAR) charts, staff files and activities programmes and all areas of the home were seen. 23 service users, 12 members of staff and 2 visitors were spoken with. A pre-inspection questionnaire was completed by staff at the home and returned to CSCI. Some information referred to in the report was obtained from the questionnaire. The people living at the home prefer to be known as residents and that is the term that will be used throughout the report. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. What the service does well: Staff interacted with residents in a friendly manner and respected their privacy. Residents are encouraged to participate in activities and to maintain contacts with their family and friends in the community. The meals served looked well balanced and appetising and were being enjoyed by residents. All areas of the home were clean, well presented, bright and freshly aired. A very attractive courtyard garden is available in the middle of the home. It was pleasing to see that progress has been made to meeting the requirements made at the last inspection, although further requirements have been made. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The contracts supplied to residents must contain the required information. Residents’ individual plans must contain details of all their care and support needs. Assessments of any risks to residents must be carried out. It is recommended that photographs of residents are attached to medication divider cards, to ensure the correct resident is identified and to prevent medication errors. The Anchor Homes complaints procedure must be suited to the needs of the residents. It is recommended that further staff undertake National Vocational Qualifications in care to level 2, to ensure that 50 or more of the staff achieve this, in line with the National Minimum Standards (NMS). Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 7 A full employment history must be obtained from anyone applying to work at the home. Staff must receive training to enable them to fulfil their role. The manager’s application for registration with CSCI must be completed. The amounts of monies held for or on behalf of residents, must accurately match the record held. The home must be kept free from hazards to the health or safety of residents. Fire doors must not be propped open, products hazardous to health must be stored in a locked provision, out of date food must be discarded, freezers must be working to the correct temperature and the kitchen cleaning schedule must be recorded. 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. Limegrove DS0000033691.V295485.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 Limegrove DS0000033691.V295485.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): 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contracts are supplied to residents but these need to contain the required information. Residents have been fully assessed before admission. EVIDENCE: Contracts detailing the terms and conditions of residence at the home have been supplied to residents. For some residents, who are being financially supported by social service departments, no details of the amounts to be paid on behalf of the resident were recorded. Copies of the agreement held between the home and social services, regarding the care and support of the resident were not held on the resident’s file. It was of concern that a resident who was known to have mental health needs, had signed a contract without this being witnessed or being signed by a representative of the home. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 10 A number of residents have recently been admitted and records of the assessment of their needs were seen. This had been carried out before admission as required. The senior carer stated that intermediate care is not provided in the home. A requirement has been made regarding Standard 2. Limegrove DS0000033691.V295485.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ individual plans require more detailed information to adequately guide staff. The healthcare needs of residents are well met and medication appears to managed appropriately. EVIDENCE: Although individual plans, known as Individual Lifestyle Agreements (ILA’s), are held for each resident, some of those seen did not provide enough detail about the residents’ present needs. It would be difficult for a member of staff to know the detailed support and care needs of residents from the information available. For two residents who moved into the home approximately six weeks ago, no details had been completed in the ILA sheets which form the bulk of the individual plan. The deputy advised that the Anchor organisation is in the process of redesigning individual plans for residents and that the current form of the ILA will be not be continued. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 12 For other residents, some information was absent or conflicting information was present in the individual plans. The personal details form for two residents were incomplete and one did not state the resident’s next of kin or general practitioner. For another female resident a record had been made that the resident preferred to receive personal care from a female carer. The bathing record showed that the resident had refused a number of baths, when these had been offered by a male carer. It is required that residents or their representatives are consulted about their individual plan, both when it is drawn up and when reviewed or updated. It is recommended that wherever possible, the resident signs their individual plan to show they were consulted. Where a resident is not able to sign, their representative should be asked to sign on their behalf. Assessments had been made of some, but not all risks to residents. For one resident who had a history of falls, no specific assessment had been made of this risk. An initial mobility assessment did not refer to this risk either. From the records seen and from speaking to staff, it is clear that the residents’ healthcare needs are well met, with timely and appropriate referrals made. A number of healthcare professionals are involved in the support of the residents, including general practitioner (G.P.), continence specialist, chiropodist and community nurse. The daily notes recorded that a change had been noted in a resident’ condition and this was immediately referred to the visiting community nurse. Medication was seen to be appropriately stored and administered and no gaps in the recording were noted. It was noted that photographs were not attached to all MAR chart divider cards. It is recommended that these are supplied, to enable staff to correctly identify residents and prevent medication errors. Staff were observed to speak to and interact with residents in a relaxed but appropriate manner. Residents’ bedrooms were not entered unless the resident was present or had given their agreement, and staff were observed to knock before entering. Staff were seen to offer personal support to residents in a discreet and sensitive way. Requirements have been made regarding Standard 7. Limegrove DS0000033691.V295485.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of activities and are supported to maintain contact with their friends and families. Well-balanced and wholesome meals are provided. EVIDENCE: A programme of planned activities is displayed in each unit in the home, to advise residents what is available each day. This included quizzes, cake decorating, arts and craft, singing and music, bingo and reminiscence sessions. Residents spoken to said they enjoyed taking part in these and stated that some activities are carried out on the units and others take place in the activity room. A number of residents were observed reading their newspapers, which they advised are ordered individually. The staff list provided with the pre-inspection questionnaire indicated that two activities co-ordinators are employed to meet residents’ social and leisure needs. One activities co-ordinator was spoken with and she stated that individual residents are asked about their interests and preferences or this Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 14 information is gathered from residents’ families. Another activities coordinator has recently been employed but has not carried out this role before. It was noted that although this member of staff has past experience as a carer, she has not received training specific to the activity co-ordinator role. This is required to enable the activities co-ordinators to fully meet the residents’ needs. This is referred to at Standard 29 , which relates to staff training. Residents spoke of keeping in touch with their families and friends and some residents stated that they had telephones in their rooms which enabled them to maintain contacts. Visitors were seen to be warmly welcomed to the home during the inspection. Staff were seen to encourage residents to be independent and observed to offer residents choices in their daily lives. This included asking residents when they would prefer to have personal care, if they required assistance with mobility and what they would like to eat or drink. Residents advised that they had brought personal belongings into the home to make their rooms more individual and a visitor was seen personalising her relative’s bedroom. For residents without the support of family or friends, it was pleasing to see that leaflets regarding advocacy services were available in the home. From the menus displayed and from speaking to residents, it was clear that a well-balanced and nutritious diet is provided. Residents were seen enjoying their lunchtime meal, which looked appetising and was served in attractive surroundings in the unit dining rooms. Tables were laid with tablecloths and co-ordinating table mats and each table was decorated with a small vase of flowers. Residents stated that they are offered a choice of meals in advance, and that alternatives are always available if required. Limegrove DS0000033691.V295485.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is more accessible, but has still to be reviewed. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A requirement was made at the last inspection that the home’s complaints procedure must be reviewed because it is not suited to the needs of the residents. A timescale of 6th February 2006 has not been met. The deputy manager stated that this is a corporate policy and is currently being reviewed by Anchor Homes, but has not been completed and issued to the home. This was confirmed at a recent meeting between CSCI and the managing director of Anchor Homes. The current complaints procedure has been moved to a more visible and accessible position in the main entrance hall. From speaking to residents it was clear that they knew who to speak to if they had any concerns or wished to make a complaint. The complaints record was seen and the small number of complaints recorded had been addressed promptly and to the satisfaction of the complainants. The complaints record has been changed to a numbered loose, leaf system to meet the requirements of the Data Protection Act. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 16 A number of staff have undertaken training in the protection of vulnerable adults and the prevention of abuse in the care home in recent months, and records of these were seen. Staff spoken to stated that they would report any concerns to the manager or senior in charge and would not hesitate to do so. Staff advised that they understood that their role was to protect residents. Limegrove DS0000033691.V295485.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is suited to its purpose and was attractively decorated and furnished. The home was clean and fresh and presents as a comfortable place to live. EVIDENCE: The deputy manager advised that the home was purpose built and is divided into five units, two of which accommodate twelve residents and three of which accommodate ten residents. Each unit has its own lounge, dining room and kitchen area, with spacious and light bedroom corridors. The home has been furnished in a comfortable, homely style, with soft furnishings which attractively co-ordinate with the decoration. Each resident has an individual bedroom with toilet and basin facilities attached. Bathrooms with specialist, easy access baths are available on each unit. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 18 All areas of the home were seen to be clean, freshly aired and appeared hygienic. Hand washing facilities were appropriately placed and paper towels and liquid soap were available. Staff were observed to wash their hands before serving meals and after assisting residents and to wear gloves and aprons when appropriate. Limegrove DS0000033691.V295485.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet the needs of residents and any shortfalls are covered by agency staff. The standard of recruitment practices has improved. Most staff have received training suited to their role, but not all. EVIDENCE: The senior carer stated that a number of staff had left the home recently and the record on the pre-inspection questionnaire indicated that five care assistants had left since the last inspection in November 2005. Of these one had retired and two had transferred to work at other Anchor homes. The senior carer advised that a recruitment campaign had been carried out recently, with a good response. Pending the recruitment of further permanent staff, a number of agency care staff are employed to meet the needs of residents. In addition to care staff, the pre-inspection questionnaire listed other staff employed to meet residents’ needs. These included housekeeping staff, kitchen staff, receptionists, activities co-ordinators, laundry staff, an administrator and a handyperson. The senior carer advised that she had recently changed her role from deputy manager and that a new deputy had been appointed. The new deputy was Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 20 also present during the inspection and assisted the senior carer to provide the records and information required. Both staff were very supportive of the inspector and capably assisted with the inspection process. A number of staff have undertaken National Vocational Qualifications (NVQ’s) to level 2 in care. The senior carer stated that three staff have achieved this level and six staff are currently undertaking it. As this does not meet the National Minimum Standard for Older People, which states a minimum of 50 or more of the care staff trained to this level, it is recommended that further staff undertake this training. The staff training records were seen and these demonstrated that most staff are receiving training according to the role they carry out. This included training required by law, such as first aid, fire safety and food hygiene and other training to develop knowledge and skills, such as rights and responsibilities and basic health and safety. It was noted however that some members of staff had not received training for their role. A recently employed housekeeper has not received training in the use and Control Of Substances Hazardous to Health (COSHH). Specifically, the activities co-ordinators and housekeeping staff must be trained to enable them to fulfil their duties. A requirement was made at the last inspection that a person must not be employed to work at the home unless they were fit to do so, that the records and documents specified in Schedule 2 of The Care Homes Regulations had been obtained in respect of the person, and that this must include a full employment history. It was also required that the employer must be satisfied on reasonable grounds as to the authenticity of any references supplied. This was made with immediate effect and has been partially met. From the recruitment records of recently employed staff, it was noted that one applicant had provided an eight year employment history, although their age would indicate a longer working life was more likely and should be explored. For one applicant, no interview questions were available, so it was not possible to ascertain why they had been selected for their role. Requirements have been made regarding Standards 29 and30. Limegrove DS0000033691.V295485.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 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager has applied for registration with CSCI. Surveys have been carried out to assess residents views. Residents’ monies must be managed more robustly to protect against financial abuse. Safeguards must be maintained to protect residents from hazards. EVIDENCE: The home manager has applied for registration with CSCI and this is currently being processed to assess her fitness for the role. The manager has already undertaken the NVQ Registered Manager’s Award and NVQ Level 4 in care and is an NVQ assessor. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 22 The senior carer stated that a Quality Assurance survey was carried out by a national company who are independent of Anchor Homes earlier this year, but in the absence of the manager, the report of this was not available. It is requested that the report is forwarded to CSCI Surrey area office, as required. The administrator stated that monies are held for a number of residents for safekeeping. The administrator manages the monies on a day-to-day basis and is overseen by the manager. The amount of money held in the residents’ cash tin was checked with the administrator. It is of serious concern that the amount present did not accurately match the record held. Records of transactions were seen and residents had signed when making deposits or withdrawals. It was noted that the members of staff handling transactions had not signed all entries, even though the sheet had a space for this. Where a resident’s representative had made a deposit, the representative had not signed the record. It is strongly recommended that for all transactions two signatures are recorded, to safeguard residents and staff. A requirement was made at the inspection carried out on 7th November 2005 that the record of monies held for safekeeping on behalf of residents must accurately match the amount held. This was given an immediate timescale but this has not been met. The management of residents’ monies in the home must be carried out more robustly to safeguard against financial abuse, particularly as this is the second occasion when an error has been noted. Regular checks should be made by two people and these should be recorded clearly in the ledgers and records. Records relating to health and safety were sampled. These included fire alarm testing and drills, water temperature testing, hot food temperatures, fridge and freezer temperatures and these checks had been carried out to the required frequencies. It was noted that one freezer in the kitchen was not maintaining the required temperature. The chef present stated that the engineer had been requested to attend to the freezer. The home displayed an up to date gas safety certificate, a current certificate of employers liability insurance and a health and safety at work poster and the current electrical safety certificate was seen. Accident records were seen to be recorded appropriately on individually numbered record sheets. The kitchen area was inspected and appeared to be clean, with foods appropriately stored. It was of concern that the kitchen cleaning schedule had not been completed for three weeks. The chef present stated that the cleaning had been carried out but he had forgotten to complete the schedule. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 23 A requirement was made at the last inspection that all parts of the home to which resident have access are so far as reasonably practicable, free from hazards to their safety. This was with immediate effect but has not been met. It was very disappointing to note that the fire door which was seen propped open on the last inspection, was in this position once again. An unlocked cupboard in one of the unit kitchens was seen to contain hazardous products and an out of date jelly was seen in a fridge on one of the units. Requirements have been made regarding Standards 35 and 38. Limegrove DS0000033691.V295485.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 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 1 x x 1 Limegrove DS0000033691.V295485.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 OP2 Regulation 5 (1) (b & c) Requirement Each resident must be provided with a contract or statement of terms and conditions of their residence, containing the information specified in Regulation 5. Timescale of 05/12/05 not met. Each resident must have a written plan detailing all the care and support needs of the individual and this plan must be available at all times. Timescales of 30/04/05 and 05/12/05 not met. Timescale for action 04/08/06 2 OP7 15 03/07/06 3 OP7 3 OP16 13 (4) (c ) Unnecessary risks to the health or safety of residents must be identified and so far as possible eliminated. Risk assessments must be carried out for any known or identified risks to residents. 22 The Anchor complaints procedure must be appropriate to the needs of the residents. Timescale of 6/02/06 not met. 01/06/06 01/09/06 Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 26 4 OP29 19 (1) (ac) 5 OP30 18 (1) (c) (i) The registered person must not employ a person to work at the care home unless the information and documents specified in Schedule 2 have been obtained in respect of that person, which includes a full employment history. The registered person must ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. Specifically the activities co-ordinators and housekeeping staff must be trained to competently perform their roles. Timescale of 06/02/06 not met. The manager’s registration with CSCI must be completed. The report of the recent review of the quality of the service provided, must be forwarded to CSCI. The registered person must maintain in the care home the records specified in Schedule 4 and these records must be kept up to date and available for inspection. Specifically, the amount of monies held for safekeeping on behalf of residents must accurately match the record held. Timescale of 07/11/05 not met. The registered person must ensure that all parts of the home to which residents have access are so far as reasonably practicable, free from hazards to their safety. Timescale of 07/11/05 not met. 01/06/06 01/09/06 6 7 OP31 OP33 9 24 01/09/06 30/06/06 8 OP35 17(2) Schedule 4 01/06/06 9 OP38 13 (4) (a) 01/06/06 Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 27 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 OP9 OP28 Good Practice Recommendations It is recommended that photographs of residents are attached to medication divider cards, to ensure the correct resident is identified and to prevent medication errors It is recommended that further care staff undertake NVQ level 2 in care, to enable the home to meet the National Minimum Standard of 50 of care staff trained to this level. Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Limegrove DS0000033691.V295485.R01.S.doc Version 5.2 Page 29 - 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!