CARE HOMES FOR OLDER PEOPLE
Little Hayes Care Home 29 Hayes Lane Kenley Surrey CR8 5LF Lead Inspector
Alison Ford Key Unannounced Inspection 15th January 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 Little Hayes Care Home DS0000019033.V357639.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. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Little Hayes Care Home Address 29 Hayes Lane Kenley Surrey CR8 5LF 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 8660 6626 020 8668 2449 littlehayes@btconnect.com Diplotec Ltd Julia Barbara Christodoulides Care Home 50 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (40) of places Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Daytime staffing levels would have to be:4 Qualified nurses and 8 care assistants between 8:00am and 2:00pm. 3 Qualified nurses and 7 care assistants between 2:00pm and 8:00pm. Nighttime staffing levels would have to be: 2 Qualified Nurses and 3 Care assistants between the hours of 8:00pm and 8:00am. 29th June 2007 2. Date of last inspection Brief Description of the Service: Little Hayes is a 50-bed home, which offers nursing care to the elderly. The home is situated in Kenley, an attractive semi-rural area that is in close proximity to a mainline rail station and good road and bus links. The only potential difficulty with access is that the visitors on foot would have to climb a short, but steep hill to the home. The home offers 36 single bedrooms and 7 double bedrooms over two floors. There are two passenger lifts for ease of access although the home is very spread out in its layout and it is quite disorientating at first. The stated aim of the home is to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort is of prime importance. Copies of the Statement of Purpose for the home and the latest inspection report can be requested from the home. Inspection reports can also be obtained from The Commission for Social Care Inspection via the internet. At the time of this latest inspection fees ranged from £416 - £680 depending on the room occupied and the dependency of the resident. These and any extra charges payable would be discussed prior to admission. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second key inspection of the year 2007 / 2008 and was an unannounced visit. During this time a partial tour of the premises was undertaken, several of the 39 residents currently living in the home, and some of the staff members were spoken with. Three care plans of residents admitted since the last inspection were seen and various records, that the home is required to keep as evidence of its commitment to the health and safety and well being of the people who use the service, were also seen. In compiling this report consideration has also been given to other information made available to The Commission throughout the inspection year, which includes complaints and notification of incidents. In addition the Registered Manager has completed an Annual Quality Assurance Assessment. This document has to be completed every year and is designed to give those people who own and manage care homes the opportunity to tell us how they support those who use their service, how they provide care and what they intend to do in the future. Fees at the time of this inspection ranged from £416- £680 depending on the room to be occupied and the dependency of the resident. However, the annual increase is due to be applied in April. Notification of this will be going out in the near future. Some extra costs may be payable for services such as newspapers and hairdressing and these would be discussed prior to admission. What the service does well:
The people who live in this home tell us that it is comfortable and clean, staff are kind and they especially enjoy the activities that are arranged for them. Several of them said, ”its nice living here” and they all agreed, “the food is always very good”. They are able to choose how they spend their days in the home, what time they go to bed in the evenings and the meals that they eat. Some of the residents are very frail and others have dementia so they are not all able to offer any input into the inspection process however, they seem to be happy and they look well cared for. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 6 The relative of one resident, with very complex care needs, explained how he was always included in things that were going on even though he was unable to contribute and that they appreciated this. They said how kind staff were; always respecting residents individuality and that care was always consistent whatever time of day they visited. Staff turnover within the home is quite low and residents benefit from a continuity of care that is familiar to them. Pre admission assessments are always undertaken prior to any resident being admitted into the home even when this entails travelling long distances; one resident had recently moved into the home from Southend. The Registered Manager is then able to judge whether that the home will be able to provide the care and support that will be needed and make sure that staff have the necessary skills and training. They would be given copies of the homes Statement of Purpose, The Service User Guide and the latest inspection report in an A5 booklet format to take away to read. This will help them and their relatives decide whether the home and the services provided will suit them. Individual care plans are then drawn up which outline all of the care and support that residents will need. These ensure that all staff know exactly how people prefer to be supported and a regular review makes sure that any changing needs are identified. Daily activities are offered to interest and stimulate residents and there is a dedicated and enthusiastic activities coordinator. On the day of the inspection residents were preparing to play bingo and photographs on the wall showed the table decorations that they had made for Christmas. Some residents told us about trips out of the home that they had been able to go on and there were pictures of these displayed in the hall. It was disappointing to hear that the minibus is no longer in operation and it is hoped that a new one will be able to be purchased in the very near future. Visitors are always made welcome into the home. Policies and procedures are in place to ensure that the health and safety of residents and staff is protected and training is given a high priority so residents can be confident that staff will have the skills and expertise to meet their needs. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
In order for this home to remain a pleasant environment for the people living there, the outside now needs some attention. Rendering needs to be redone and some of the woodwork is rotting around door and window frames. On the day of the inspection it was raining and the gutters were obviously leaking. The driveway, which is very steep, is uneven with potholes and it is considered that this is a risk to both residents and visitors some of whom may be quite elderly. Also there is a broken window in the garden lounge, which will need to be repaired before the warm weather. Some furniture in the communal areas is also quite shabby and needs replacing. There has recently been some reduction in staffing levels in the home. The cook no longer works in the evening, which means that there is not a hot snack meal available in the evening. Soup and sandwiches are prepared before she leaves in the afternoon. This change will need to be reflected in the printed menus in the dining room and in The Service User Guide that residents are given. Residents will need to be given the opportunity to comment on whether they are happy with these changes. Trained nurse numbers have also been reduced at night. While it is acknowledged that the home is not currently full, the layout, which is quite “sprawling” will make it difficult for one nurse to supervise the care staff
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 8 effectively. Records of accidents and incidents must be audited regularly to make sure that there are enough staff available at night to meet the needs of the people in the home. At the time of this inspection residents seemed to be very happy with the care that they were receiving although two of them commented on their perception that there were not enough staff. This situation will be monitored carefully. 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. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 9 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 Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 10 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): Standards 1,3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service have access to good information to help them to make an informed choice about the suitability of the home. Pre-admission assessments are undertaken which judge the homes suitability to meet the healthcare needs of any one considering moving in. This home does not offer intermediate care; this standard does not apply. EVIDENCE: Prior to admission, any potential resident would have an assessment, done by a senior member of staff, to make sure that the home would be able to provide appropriate care and support for them.
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 11 Care plans of 3 residents admitted since the last inspection were seen and there was evidence that all aspects of their physical and psychosocial healthcare needs had been carefully considered during this process. A care manager’s assessment is also provided for residents whose care is funded by the local authority It was felt that the information that is given to potential residents is particularly useful. Copies of the Statement of Purpose, Service User Guide, and the latest inspection report have been produced in A5 format. These are left with the person to read, in order to help them decide if the home will suit them. Consideration is now being given to developing them in different formats and languages. They would also be encouraged to visit prior to admission, if they were able, to see if they liked it. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 12 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 7,8,9,10.11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service all have an individual care plan which reflects the care and support that they currently require. They can be sure that they will be treated with dignity and in a manner which reflects their privacy. Appropriate measures are in place to ensure that they are protected by the homes medication procedures. Additional staff training is now being undertaken to ensure that they receive the best possible care in the latter stages of their lives. EVIDENCE: Three care plans were seen at this visit. These have continued to improve over the last year. They are more comprehensive and identify all aspects of residents physical and pschosocial needs where they may need support. There
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 13 is also evidence of “life history work” that provides information about residents previous lives and achievements helping staff to understand them and to plan activities that will interest them. Residents would be involved in their care planning if they were able, otherwise their families or representatives are invited to participate in the process. Bodymaps are in place in the care plans which provide evidence of the skin integrity of residents at the time of their admission in to the home. Factors which could identify any deterioration in their health or lead to the formation of pressure sores are monitored regularly and nutitional assessments are in place. Risk assessments are undertaken to identify those who might be prone to falling and care plans spacific to night time hours are completed. Care plans are audited regularly so that any changes are identified. Medication storage and administration are in good order. In response to a previous concern, trained nurses have been reassessed to confirm their competence and medication records are audited regularly. The people that we spoke with said that staff are kind and caring though they think that there are not always enough of them on duty. A relative said how they felt staff treated people with a great deal of respect for their individuality. Qualified nurses and senior carers in the home have been working with the local hospice, receiving training to help them care for people who are dying. The manager explained that she was hoping to start working towards becoming accredited for The Gold Standard Framework. This is a communitybased initiative, which aims to ensure that people receive the best possible care, according to their individual wishes, at the end of their lives. Little Hayes Care Home DS0000019033.V357639.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 12,13,1415 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service are encouraged to make choices within their daily live as much as their abilities allow and a varied programme of activities is in place to offer interest and stimulation.They consider that that meals are well presented and suit them. Their visitors are always welcome into the home. EVIDENCE: There is a dedicated activities organiser in the home and people said how much they enjoyed the various things she organised for them. Residents are free to join in or not, as they wish; on the day of the inspection they were waiting to play bingo. There are pictures around the home that illustrate various events and trips out that have occurred. At Christmas time they made the table decorations and various pieces of artwork are also displayed. Minutes of residents meetings also reflect their comments about how much the activities that are arranged have been appreciated. They particularly like some of the entertainers that visit and one act had been asked back at Christmas
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 15 “ by popular demand”. It was disappointing to note that the minibus had broken down and repair was thought to be uneconomical. It is to be hoped that this will be replaced. Relatives and friends of residents are encouraged to visit the home whenever they wish. One relative, spoken with, said she was always welcomed and offered a cup of tea whenever she turned up. All those spoken with agreed that the food served in the home was very good and there was always a choice. The lunchtime meal was observed and looked very appealing. Menus have recently been revised after consultation with residents and they are displayed in the dining room. The cook speaks with residents regularly to make sure that they are happy with the meals that she is cooking. Unfortunately the cook no longer works in the evening therefore the hot snack option that is on the menu for suppertime is not available. Residents now only have soup and sandwiches, which are prepared before she goes off duty in the afternoon. This is despite the Service User Guide stating that there will be a choice of soup a hot dish or sandwiches in the evening. This is considered to be a retrograde step and the views of residents will be monitored at future visits. Meanwhile, the menus and Service User Guide must be amended to reflect the change if it is to continue. Little Hayes Care Home DS0000019033.V357639.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): Standards16, 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people who use this service know that there are policies and procedures in place to respond to their concerns and they are sure that any complaints will be listened to and acted upon in a timely manner. Procedures are in place to help safeguard them from abuse. EVIDENCE: There is a complaints procedure and copies of this are in the Statement of Purpose and Service User Guide. Forms and a complaints book are in the entrance hall and available to anyone. The complaints register was seen and the three complaints that had been made since the last inspection had all been dealt with appropriately and resolved. Staff displayed knowledge of issues around adult abuse and there is ongoing training within the home. Some of them have received training regarding the Mental Capacity Act and this will be extended to all staff. Robust pre-employment checks are in place to ensure residents protection from those who have been judged as being unsuitable to be working with vulnerable people. Little Hayes Care Home DS0000019033.V357639.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people who use this service say that they live in a clean and comfortable home that suits their needs however, a programme of maintenance and refurbishment is needed to ensure that it remains safe and pleasant for them. EVIDENCE: A tour of the premises was undertaken and the home was clean and tidy. A redecoration programme has been completed within the last year and keypads have been fittted so that residents could not leave the home unnoticed and to prevent intruders. There are handrails around the home to help those residents who are able to walk, areas have been colour coordinated to help orientate them and they are able to lock their bedroom doors if they wish to. Automatic door closers mean
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 18 that they are able to leave their bedroom doors open if they want to without compromising theuir safety in the event of a fire. Some of the lounge furniture is quite scruffy and would benefit from being replaced. Residents were informed at the September residents meeting that quotes had been obtained for this however, nothing seems to have happened since that time. Rendering to the outside of the property and window and door frames are in need of attention; the paintwork is chipped and peeling and frames are beginning to rot. On the day of the inspection it was raining heavily and guttering obvioulsly needs replacing. One of the windows in the garden lounge is broken and cannot be opened .This has not previously been repaired as there was a plan to add a conservatory although it has not happened as yet. This will need to be adressed one way or another before the warm weather. The driveway, which has always been hazourdous due to the steepness of the incline, is full of potholes despite attempts to repair it. This could pose a safety risk for both residents and their relatives many of whom are quite frail and elderley. Resurfacing of the drive must beundertaken. A refurbishment and redecoration plan must be produced outlining how all of these issuse will be adressed. In addition, the concerns regarding the driveway and the window are considered to be a potential risk to the healthand safety of residents and therefore have influenced the quality rating under standard 38. Little Hayes Care Home DS0000019033.V357639.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service cannot be sure that there will always be enough staff on duty to meet their needs. Recruitment practices are in place to make sure that residents are protected from those who have been judged as being unsuitable to work with vulnerable people and staff training is given a high priority. EVIDENCE: Staffing levels have recently been reduced. The number of qualified nurses on duty at night has now gone down from two to one. Given the expected workload for a trained nurse and the “sprawling layout” of the home this will make effective supervision of the three care staff at night very difficult. Currently this staffing amendment seems to have had a limited effect on the care being given to residents although 2 of them did comment that at times the home seemed short of staff. As there are serious concerns about the reduction of staffing levels at night the numbers and times of accidents and incidents occurring must be audited closely This situation will be monitored carefully to ensure that there is no impact on the outcomes for the people living in the home.
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 20 Staff training is given a high priority in the home with more than 50 of care staff having obtained an NVQ level2 qualification. Others are working towards this standard while some are studying for an NVQ level3. Statutory training has been completed and a programme has already been arranged for the coming year. Robust recruitment practices are in place with all staff having undertaken appropriate checks, before being employed, in order to ensure the protection of those people living in the home. Little Hayes Care Home DS0000019033.V357639.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that it is managed by a suitably qualified and experienced person and they are encouraged to contribute their views in order to influence the running of the home. Equipment and services are appropriately maintained and monitored. Some concerns have been raised about health and safety issues in the home. EVIDENCE: The current manager Ms Julia Christodoulides is a trained nurse with additional qualifications and previous experience in a similar role. She displayed a thorough understanding of the needs of the client group in the home and many of the residents and staff commented on how kind and capable she is.
Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 22 There are regular staff meetings held in the home and relatives and residents meetings are also held every two months. This allows residents to voice their opinions and there was evidence that their views are listened to and acted upon. Minutes of meetings showed that they had said that one of the toilets had been difficult for wheelchair users to use and this has now been altered. They had also been able to choose which entertainers they would like for their Christmas party. A regular monthly newsletter is also produced so that everyone is aware of what is happening in the home. The Registered Provider visits the home on a regular basis in accordance with Regulation 26 to ensure that everything in the home is satisfactory and prepares a report. Staff supervision is now happening on a regular basis and all staff that were spoken with explained how they had found it useful. It allows them the opportunity to talk about any concerns and to identify any training needs that they might have. Some financial transactions are undertaken on behalf of residents although their money is all banked centrally. This money would be used for services such as chiropody and hairdressing and resident’s representatives would be sent an itemised bill for this. A selection of certificates of worthiness and other records providing evidence of the homes commitment to the health and safety of its residents were all seen at the last key inspection and were all in order. Kitchen records are kept in line with new legislation. Outcomes for these standards are affected by some concerns about the health and safety of residents. As detailed in standard 19 the driveway to the home is uneven and combined with the steep incline is considered to be unsafe for both residents and their visitors, many of who may be elderly. Also the window in the garden lounge, which is broken, must be repaired before the warm weather so that it can be opened. As detailed under standard 27 some concerns are noted in relation to the recent reduction in staffing levels. This situation will continue to be monitored closely to ensure that resident safety is not compromised and the numbers of accidents and incidents must be audited closely. Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 23 Little Hayes Care Home DS0000019033.V357639.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 1 X X X X X X 3 STAFFING Standard No Score 27 2 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 1 Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 6(a) 16(2)(i) Requirement The menu and Service User Guide must be amended to reflect the fact that residents are no longer offered a hot snack meal in the evening, so that they are aware of exactly what will be available. Worn and shabby furniture must be replaced so that the home provides a pleasant environment for those who live there. There must be an ongoing programme of renewal and refurbishment of the outside of the building so that it is kept in a good state of repair. The driveway leading to the home must be repaired so that it does not pose a hazard to the health and safety of anyone visiting the home. The window in the garden lounge must be repaired so that it is safe for residents and staff. The impact of the reduction in staffing levels on resident’s care and safety must be monitored closely. Timescale for action 30/04/08 2. OP19 23(2(9d) 30/04/08 3 OP19 23(2)(b) 30/04/08 4 OP19 13(4)(c) 30/04/08 5 6 OP19 OP27 13(4)(c) 18(1)(a) 30/04/08 30/04/08 Little Hayes Care Home DS0000019033.V357639.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. Refer to Standard Good Practice Recommendations Little Hayes Care Home DS0000019033.V357639.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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
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