Inspection on 23/05/05 for The Hermitage

This inspection was carried out on 23rd May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Hermitage 28/08/07

The Hermitage 07/08/06

The Hermitage 29/11/05

The Hermitage 09/09/04

The Hermitage 21/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Hermitage 17 Dunheved Road South Thornton Heath Croydon, Surrey CR7 6AD Lead Inspector James OHara Announced 23 May 2005 09:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service The Hermitage Address 17 Dunheved Road South Thornton Heath Croydon Surrey CR7 6AD 020 8665 0204 020 8665 1084 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Surrey Oaklands NHS Trust Mrs Kim Baldacchino Care Home 14 Category(ies) of Learning disability (14) registration, with number of places The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: A variation has been granted to allow one specified service user over the age of 65 to be accommodated for as long as the home is able to meet their needs or until the placement is terminated. Date of last inspection 09/09/04 Brief Description of the Service: The Hermitage is a fourteen place residential home for people with learning disabilities, however only eleven service users live at the home at present. Some of the service users also have physical disabilities. The home is a large detached house situated in a mainly residential road in Thornton Heath, close to local shops and transport. The home is within easy reach of Croydon town centre and all its facilities. Each of the service users has their own bedroom, which is personalised to their own tastes. There is also a large dining room, communal lounge and an activities room. There is a large garden to the rear of the house, which is well used in the summer. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day. Methods of inspection included a tour of the premises observation of contact between staff and service users, interviews with a service user, a service users relative, a member of staff and discussion with the registered manager. A large number of comment cards were returned to the Commission for Social Care Inspection as feedback from service users and relatives. Records examined included Person Centred Plans, risk assessments, complaints, staffing records, training records, Criminal Records Bureau Checks, menus and service user meeting minutes. Requirements and recommendations from the previous inspection were also discussed with the registered manager. What the service does well: The quality of information provided for new service users is good. Service users have regular meetings and they are offered opportunities to participate in the day-to-day running of the home. They also have the use of two minibuses owned by the home. Service users are able to access community health facilities such as opticians, chiropodist, and dentist and district nurses. The majority of staff has completed NVQ’s. One of the service users relatives said that he is welcome to visit the home when he wishes, he just calls the home to let them know he is coming. He said that he always feels welcome and that the staff are always very helpful. What has improved since the last inspection? What they could do better: The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 6 The manager has worked at the home for approximately ten months; during this time there has been a number of improvements in the support offered to the service users including an increase in activities, support offered to staff and the décor of the home. There is evidence to suggest that further improvements are on their way. The manager is planning to review and update the Statement of Purpose and obtain new settees for the living room. The home needs to complete a risk assessment for one service user using the stairs. The inspector has not seen all staffs Criminal Records Bureau Checks as yet. The inspector would like to thank the service users and their relatives for their help and feedback and staff and management of the home for their support on the day of the inspection. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 4. Information available to prospective service users is of s good standard which would allow prospective service users to make am informed decision about moving to the home. EVIDENCE: The manager has applied to the Commission for Social Care Inspection for a variation to the homes registration as regards the service user who is 84 years old this meets the requirement from the last inspection. The registered manager has reviewed the Service Users Guide and is planning to review and update the homes Statement of Purpose. The Service User Guide has been completed in a more understandable format for the benefit of the service users. She plans to complete the Statement of Purpose in the same format. Although the home registered to support fourteen service users with learning disabilities there are only eleven service users living at the home at present. The registered manager said that there are no plans to admit any new service users at present. However should they plan to the trust has an assessment pack available for any prospective service users wishing to move to the home. The registered manager said that no service user would move to the home without a needs assessment being carried out by the new service users care manager. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 9 The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10. There have been improvements in they way the home records service users information and communicate with service user. The home is well on the way to ensuring all service users have a Person Centred Plan, which should ensure that the service users receive the appropriate levels of care required to meet their needs. EVIDENCE: The registered manager has introduced Person Centred Plans to the home. Six of the eleven service users have had Person Centred Plans completed. The service user, the service users relatives, care manager, key-worker and the registered manager have attended these. The Person Centred Plans are reviewed six monthly by the service user, the registered manager and the service users key-worker. All other service users will have a Person Centred Plan completed by July 2005. Two service users attended a Person Centred Planning training day set up for service users and their carers. Service users have regular meetings and minutes indicated that service users are offered opportunities to participate in the day-to-day running of the home. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 11 A requirement was set at the last inspection that the registered manager ensure that the service user who is 85 years old has an assessment carried out by an occupational therapist regarding him using the stairs. The registered manager explained that the occupational therapist did not feel the assessment was necessary because there was no evidence to suggest that he was unable to use the stairs or that he had a history of falls. The registered manager must ensure that a risk assessment is carried out for the service user who is 85 years old regarding him using the stairs and this risk assessment is kept under review. All staff attended training on Confidentiality and Data Protection on the 16/05/05. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14, 15, 17. There has been an improvement in the level and quality of activities for the service users in the home which increases their opportunities for personal development and leading a more fulfilling life. EVIDENCE: The home has an activities co-ordinator who works at the home on Wednesday, Thursday and Friday of each week. The home has an activities room that has a piano, a karaoke machine, puzzles, art materials and games. There is a computer located in the dining room that service users have access to. Service users have the use of two minibuses owned by the home. The home is also in the process of setting up a sensory room. Two service users attend Geoffrey Harris House day centre four days a week and one attends two days a week. Two service users are currently attending taster classes at a local college to see if they would like to enrol in September. One service user who is a Muslim has been offered opportunities to attend the local Mosque with the support of staff and her family however she chooses not to go. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 13 Service users also go to the cinema in Streatham, bowling in Purley Way, the Saturday Club, Monday Club, one service user goes to the over Sixty-five Lunch Club and an Aroma Therapist visits the home on Thursday afternoons. The registered manager explained that the homes menus were discussed and reviewed by the service user at their meeting. She said that there is now a summer and winter menu and a vegetarian option. Service users have varying degrees of contact with their relatives and friends however the registered manager said that some service users have no family and she has referred them to Croydon Advocacy Partners. One of the service users relatives said that he is welcome to visit the home when he wishes he just call them to let them know he is coming. He said that he always feels welcome and that the staff is always very helpful. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19. Arrangements made for the health care need of the service users is good as they are able to access community health facilities such as opticians, chiropodist, dentists and district nurses. Their overall health needs are being met. EVIDENCE: None of the service users at the home self medicate, all service users have the new My Health book. The My Health book is an assessment of the service users health care needs and includes a record of appointments attended. The home has only just started to use the books in the home. Service users are able to access community health facilities such as opticians, chiropodist and district nurses as required. The service users also have access to The Trust’s dentist. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has appropriate complaints and adult protection procedures procedure in place, which enables service users to feel confident that that they are protected from all aspects of abuse. EVIDENCE: The home has a book for recording complaints and all complaints. All relevant documentation includes details of the Commission for Social Care Inspection. A copy of the Croydon Councils Protection of Vulnerable Adult Policy was available in the home as well as the trust’s own procedure. Two of the relatives comment cards returned to the Commission for Social Care Inspection as feedback indicated that they were not aware of the homes complaints procedures. A recommendation has been set that the registered manager send a copy of the homes complaints procedures to all of the service users relatives. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26 and 28. There have been major improvements to the decor of the home over the last ten months and there are plans for further improvements which will contribute to improving the quality of life for the residents. EVIDENCE: During a previous inspection it was noted that the décor of the home was poor. A number of requirements set have now been met. Service users bedrooms have been decorated to their own personal choices. One service user who uses a wheelchair has moved to a bigger room, she said that she is very happy with her new room. During a previous inspection it was noted that the dining room looked more like an office. All of this documentation has been moved from the dining room or stored away out of sight, working documents and key cabinets have been relocated to the office, dining room furniture has been rearranged. The dining room now looks like a dining room. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 17 On this occasion standards 25 and 26 have been graded as a 4 (Commendable) for the considerable improvements to the décor of the home and other arrangements made for the benefit the service users. The living room has four settees, however some of the seating is missing and the furniture is badly worn. The registered manager said that there are plans to buy new furniture for the living room. The registered manager must ensure that new settees are purchased for the living room. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34 and 36. Staff at the home appear to be well trained and supervised which contributes to service users being supported by a competent and qualified staff team. EVIDENCE: The home manager said that when she started working in the home not all staff training records were kept on file. She has completed a training programme for all staff at the home. Staff has recently attended training on Fire Safety, Manual Handling and Confidentiality. The manager is planning further staff training to be completed this year on Health and Safety, Vulnerable Adults and Food Hygiene. Six staff and the manager and the deputy manager have all been trained on First aid and staff has had training on Medication. Eleven members of staff has completed NVQ level 2 and two members of staff has completed NVQ level 3. The registered manager is assessing another member of staff completing NVQ level 3. The home has the support of a Domestic and she is also completing an NVQ. Eleven of sixteen staff Criminal Records Bureau Checks were available for inspection. The registered manager must write to the Commission for Social Care Inspection when she receives the other five members of staffs Criminal Records Bureau Checks and arrange a date for these to be inspected. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 19 There was evidence that staff receive regular supervision. The registered manager explained that the previous deputy manager has been redeployed to another home in the service and that she has a new deputy manager. The new deputy manager has had training on supervision and will, when she settles into the home, start to supervise staff. Information contained in the staff files has been archived as required at the last inspection however staff files should include a recent photograph. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37. Although the registered manager has only worked at the home for approximately ten months he has brought about a number of improvements in the support offered to the service users, an increase in activities, support offered to staff, record keeping and the décor of the home. If this continues and is consolidated the service users can feel confident that the home is well run and their welfare is safeguarded. EVIDENCE: The registered manager has worked in and managed other Registered Care Homes within the Trust over the last nine years. She is currently completing the Registered Managers Award and NVQ level 4 in Care. She is also a Registered Nurse and she also holds NVQ units D32 and D33 enabling her to assess staff completing NVQ’s. On this occasion standard 37 has been graded as a 4 (Commendable) for the commitment to improving the service shown by the management and staff of the home. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 21 The Trust has carried out an audit of the homes finances 15/03/05 as required at the last inspection. SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 4 4 x 3 x x Standard No The Hermitage Standard No 31 32 Score 3 3 Version 1.20 Page 22 G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc 11 12 13 14 15 16 17 3 3 x 3 3 x 3 33 34 35 36 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 4 x x x x x x The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 23 No. Are there any outstanding requirements from the last inspection? 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 9. Regulation 13(4)a. Requirement Timescale for action 31/08/05 2. 3. 24. 34. 23(2)g. 19(1)b. 4. 1. 4(1) The registered manager must ensure that a risk assessment is carried out for the service user who is 85 years old regarding him using the stairs and this risk assessment is kept under review. The registered manager must 31/08/05 ensure that new settees are purchased for the living room. The registered manager must 31/08/05 write to the Commission for Social Care Inspection when she receives the other five members of staffs Criminal Records Bureau Checks and arrange a date for these to be inspected. The manager must ensure that 31/08/05 the Statement of Purpose includes details as stated in Schedule 1 of the National Minimum Standards Care homes for Adults 18-65. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 24 No. 1. 2. Refer to Standard 22. 34. Good Practice Recommendations A recommendation has been set that the registered manager send a copy of the homes complaints procedures to all of the service users relatives. Staff files should include a recent photograph. The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 The Hermitage G53-G53 S25850 TheHermitage V195018 230505 Stage 4.doc Version 1.20 Page 26 - 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. 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