Inspection on 24/05/06 for The Hermitage

This inspection was carried out on 24th May 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

The Hermitage 07/01/09

The Hermitage 26/02/08

The Hermitage 17/10/05

The Hermitage 20/04/05

The Hermitage 16/11/04

The Hermitage 01/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Hermitage 66 Holly Road Uttoxeter Staffordshire ST14 7DU Lead Inspector Sue Jordan Key Unannounced Inspection 24 May 2006 09:50 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 The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hermitage Address 66 Holly Road Uttoxeter Staffordshire ST14 7DU 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) 01889 562040 01889 565299 Doctor Charles Bamford Convalescent Home Trust Ann Louise Hurst Care Home 15 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (15), of places Physical disability over 65 years of age (6) The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: The Hermitage, a large detached Victorian house has been extended to provide accommodation for 15 older people, Six of whom may be physically disabled and three of whom may have dementia care needs. The home is provided by the trustees of the Charles Bamford Memorial Trust and managed by Care Manager, Louise Hurst. The home is situated close to the centre of the market town of Uttoxeter and within easy walking distance of local shops and a public house. A bus route passes the end of the drive. Accommodation is provided in three double and nine single bedrooms, none of which have en-suite facilities. One double and six single bedrooms are situated on the ground floor. Access to the first floor is by staircase that has been fitted with a stair chair lift. Communal facilities consist of a large lounge and a dining room. At the time of this inspection the weekly fees charged range from £347-£367. At the time of this inspection there were nine service users resident at The Hermitage. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over eight hours. This was a ‘key inspection’ and therefore all of the core standards were assessed. The methodologies used were scrutiny of the pre-inspection questionnaire completed by the manager, nine Commission for Social Care Inspection comment cards and the Home’s service history. Discussions were held with a number of the residents, the manager, the administrator, a visiting relative, and four staff members. Case tracking of two residents was undertaken, which included discussions and checking of their records. Observations were made of staff and service user interaction and non-personal care tasks. The records for two members of staff were checked. A random selection of the Health and Safety records were seen and the medication systems examined. A tour of the environment was taken. Since the last inspection on 17/10/2005, the Commission for Social Care Inspection has registered the manager, Louise Hurst and Additional Visits were carried out on 04/01/06 and 03/03/06. What the service does well: The management and staff make the residents’ relatives welcome and there are frequent visitors to the Home. Staff recruitment procedures are robust and appropriate Protection of Vulnerable Adults and Criminal Records Bureau checks are undertaken for prospective staff. Previous improvements relating to the provision of mandatory training have been sustained. 72 of the staff team have achieved NVQ 2 or above. Health and safety continues to be high priority and the environment is clean and hygienic. Staffing ratios are high and there is a fairly consistent staff team. The manager keeps the Commission for Social Care Inspection informed of any significant events or changes in the Home. The trustees and the manager have a history of co-operation and compliance with the Commission for Social Care Inspection. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Although assessments are undertaken for all prospective residents, this must be continued as and when necessary. A better awareness of risk and the need for a subsequent assessment is required. These risk assessments should be enabling rather than disabling and provide staff with the action needed to prevent difficulties and encourage independence. Care planning must be expanded to include residents receiving respite care. The manager and staff team should, together with the residents, explore further the whole issue of choice and flexibility for the service users to ensure that the daily routines suit the individual resident and are not being imposed by the staff. Staff resources could be used more effectively to initiate more activities and access to the community. It is strongly recommended that staff take staggered breaks in order that there are care staff available to the residents at all times. The residents require safe physical access to the grounds and the community and should consider fitting suitable ramps and handrails. The residents tend to favour the downstairs bathroom and as a result it is showing signs of wear and tear. It is also very cluttered. It is recommended that this room be given priority in the maintenance programme. Should the home expand suitable facilities must be provided for service users to meet privately with their visitors, which is separate from their own bedrooms and room for the storage of equipment. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 7 It was identified that more attention must be paid to induction training. The manager must implement an effective supervision system for staff. 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 Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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 The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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): 3, 6 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Assessments are undertaken of prospective residents, however these need to be expanded to ensure that any risk is clearly identified and the preventative measures explained. This will further safeguard the residents and staff. EVIDENCE: There have been no permanent admissions to The Hermitage since the last inspection, however a number of ladies have stayed at the Home for respite care. The records of one such lady were checked and although the manager had completed an assessment, a subsequent care plan had not been developed. It was explained that this is because of the implementation of a new computer system. The care records for three residents were checked and it was identified that some risks had not been assessed. For example, diabetes and the prevention The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 10 of a hypoglycaemic attack and the safe use of a hoist. The manager must ensure that risks are identified and an assessment undertaken. The Hermitage does not provide intermediate care. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Overall improvements made since the arrival of the new manager must be sustained to ensure that the staff have all of the information and guidance required to meet individual care needs and that daily routines and practices respect the rights of the residents within their own Home. EVIDENCE: A new computerised care planning system has been introduced, which when fully operational will cover all the required areas of need. Staff are enthusiastic about the new system and have received ‘in-house’ instruction. They are to receive more formal training in the near future. The records are protected and staff are only allowed access to information they are required to know. The entries are written contemporaneously and past entries cannot be amended or tampered with. It was recommended that a ‘hard copy’ of individual care plans also be available and a system introduced for maintaining its currency. This will insure against computer failure and also ensure that the residents and/or families have access. The care records are reviewed monthly. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 12 It was identified that risk assessment requires expansion. The care records for three residents were checked and although the manager had completed an assessment for a resident receiving respite care, a subsequent care plan had not been developed. The manager must ensure that the staff have the information required to deliver care to all service users, including those receiving respite care. The manager was advised that the daily records should contain more pertinent information. It must be noted that major improvements have been made to the care records and care planning since the new manager commenced employment at The Hermitage. The care records contain evidence of medical, health appointments and visits. However a questionnaire completed by a community nurse remarked that communication between management and staff required improvement. Problems with communication between some staff members were identified during this inspection and requirements have been made accordingly. The manager must ensure that all staff follow the guidance given by the health professionals, which should be included in the relevant section of the care plan. The community nurse also commented, “otherwise, I find the standards that I have observed in the Home satisfactory.” One of the residents said that she would not like to be ill in The Hermitage. This comment focussed around staff availability, which was identified as insufficient. This is not as a result of low numbers of staff, but rather staff routines, which need changing to ensure that there are always staff on hand. Staff have been trained to understand and care for residents with diabetes. This includes diet and the action needed in the event of a hypoglycaemic attack. This information needs to be included in a risk assessment. The medication systems were checked during this inspection. Generally they are adequate and will be further improved by the purchase of a ‘drugs trolley’. The local pharmacist visits the Home to undertake an audit of the procedures used and most of the staff have now undertaken the ‘safe handling of medicines’ course. There was a small error in the recording of the controlled medication and the manager was required to implement a safer system of monitoring. Therefore, a recommendation was made that controlled medication be checked and stock control recorded every night. The manager should also monitor this on a regular basis. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 13 Generally the staff were observed to be polite and respectful to the residents and the majority of the residents confirmed this. However, comments by some residents and staff indicated that this varied dependent on the member of staff. Two of the seven comments card completed by residents stated that the staff ‘sometimes’ treated them well. It was also identified that some of the care practices in the home are ‘institutionalised’ and that some staff require further instruction and guidance regarding the rights of the service users and the ethos of individual choice. A requirement has been made under National Minimum Standard 14, which following compliance will ensure that the services users are given full respect. The manager has identified that she needs to ascertain the wishes of the residents and/or their families with regard to death and dying. There is an appropriate section available within the computer programme. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The manager is proactively seeking the views of the residents, with regard to their required activities and whether they are happy with the food. However she needs to explore, with the staff team further ways of creating flexible lifestyles for the residents in order that ‘institutionalised’ staff practices are avoided. EVIDENCE: The manager has recently held a residents’ meeting and questionnaires have been completed in order to ascertain what activities are wanted. A monthly bingo night has been introduced, which was confirmed as a success and the staff involved were praised for their hard work. Keep fit is available bi-weekly and an organist visits the Home monthly. The residents wish to be involved in designing the new garden area and a trip to a garden centre is being planned. One of the relatives visits the Home and has instigated a regular game of dominoes. The manager has recently been allocated a specific budget for the organisation of activities. On the day of the inspection, the ladies had their hair done by a mobile hairdresser. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 15 A plan of activities is available in the lounge area. One residents regularly goes to church and Holy Communion is available monthly for those that require it. The Home has the benefit of high staffing ratios, however this does not appear to be being used to full advantage and it was noted that, particularly in the morning, the staff take their breaks together and spend a lot of time in the staff room. It was recommended that staff be allocated to spend more time with the residents, which could be used to undertake activities with groups or individuals or accompany residents into the local community. One of the residents likes to go out into the local community and has to ask permission to leave and enter the Home. She said that she feels like a prisoner and wishes to be able to physically leave and enter the Home freely. This does appear to depend on the attitude of the staff on duty, with some making her feel more able to ask. It is accepted that the risks may need assessment, however these should not be unnecessarily disabling and respect the residents’ right to take risks. A compromise is required that complies with fire safety but staff should be encouraging this wish for independence. The manager has had discussions with the resident, however a suitable and amicable solution has yet to be reached. It was recommended that this issue be addressed as a complaint and investigated fully. Safe entrance and egress to the Home is also inhibited by unsuitable conditions and the Home should consider fitting suitable ramps and handrails. It was identified that it is ‘common practice’ for residents to be bathed after 6pm and that some staff do not offer this option at any other time. It was also established that a morning cup of tea is given to every resident at 6am and breakfast served to all at 8.30am. It was questioned whether this is based on individual choice or because ‘its always been done’. The manager was asked to explore this with staff, to ensure that individual choices are offered on a daily basis, to encourage more flexibility and avoid ‘institutionalised’ practices. Visitors are made welcome to the Home. The residents were provided with an excellent lunch on the day of the inspection and all praised the quality of the food. Some have previously raised concerns about the food with the manager, at a residents’ meeting and changes have been made to the menus. A six-weekly menu is now available. The residents are offered alternatives to the menus, if required and good quality produce is purchased. An environmental health visit took place in February 2006 and the recommendations followed. The staff have had instruction from the local diabetic nurse with regard to appropriate diet and nutrition and all staff have undertaken food and hygiene The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 16 training. The cook has attended food hygiene and food safety in catering training. The Home employs catering staff to cover the varying meal times, however the manager must ensure that this does not encourage rigid routines and inflexibility. The Home has an attractively positioned dining room and the residents are able to eat in comfortable surroundings. It was suggested that some staff eat their meal with the residents, rather than in the staff room. This could help to create a more homely atmosphere and provide an opportunity for staff-resident interaction. It would also ensure that the residents are being subtly supervised, in case of difficulties or should they require assistance. Of the seven questionnaires completed by residents for the Commission for Social Care Inspection, four said they liked the food, two said they did not and one said that they sometimes liked it. The manager will need to continue to monitor this situation. One of the visitors said that her mother looked so much better since entering the Home, that she had put weight on. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The manager is introducing systems, which will hopefully encourage a more open culture for people wishing to express concerns. This will be better evidenced by the implementation of a complaints log. EVIDENCE: The manager has received two complaints since the last inspection and has responded promptly and appropriately. However it is recommended that manager introduce a complaints log, which includes details of any investigation undertaken, subsequent action and the outcome. It was also recommended that the individual issue of being able to leave and enter the Home be addressed as a complaint and investigated fully. Of the seven questionnaires completed by residents for the Commission for Social Care Inspection, two said that they did not know whom to approach if unhappy with their care. The manager will need to re-iterate this with the residents and ensure that they all have a copy of the complaints procedure. The manager has held two residents’ meetings and sent out quality audit questionnaires. The staff have all received Protection of Vulnerable Adults training and all new staff undergo the appropriate recruitment checks. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 26 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. There have been a number of improvements to the environment in the last twelve months and a programme of maintenance is now in place. The manager is aware of the improvements needed to enhance the surroundings for the residents. EVIDENCE: A new ‘nurse-call’ system was fitted in The Hermitage in February 2006 and a new fire alarm system is due to be fitted shortly. The fire alarm systems are tested at the appropriate frequencies. Many improvements have been made to the Home’s environment in the last twelve months particularly with regard to Health and Safety. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 19 The manager reports having a monthly maintenance budget and she is presently obtaining quotes for re-decoration of the Home. The Hermitage was clean and hygienic on the day of inspection. Some areas of the Home are in need of re-decoration as identified by the manager. The residents tend to favour the downstairs bathroom and as a result it is showing signs of wear and tear. It is also very cluttered. It is recommended that this room be given priority in the maintenance programme. The Home must ensure safe entrance and egress to the Home and access to the grounds and should consider fitting suitable ramps and handrails. Should the home expand suitable facilities must be provided for service users to meet privately with their visitors, which is separate from their own bedrooms and room for the storage of equipment. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Staffing ratios are high in the Home and there is a fairly consistent staff team, supported by sound recruitment procedures and training opportunities. However, the manager must ensure that staff are fully aware of residents’ rights and the need to encourage choice and flexibility. EVIDENCE: Staffing ratios in The Hermitage are high. This includes auxiliary staff. It is strongly recommended that staff take staggered breaks in order that there are care staff available to the residents at all times. Thirteen of the eighteen care staff have achieved NVQ 2 in care or above and are to be commended for their efforts. The Hermitage does not use agency staff. Previous improvements in staff recruitment have been maintained to a high standard. Staff training continues to improve and there is evidence that staff receive mandatory training at the appropriate frequencies. A number of courses have been planned for the near future. It was identified that more attention must be paid to induction training. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 21 As a result of some of the issues raised at this and some previous Commission for Social Care Inspection inspections, the manager must ensure that staff are fully aware of residents’ rights and the need to encourage choice and flexibility. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Recent improvements to the managerial systems in the Home must be sustained and will be enhanced by closer supervision of staff and the daily routines. EVIDENCE: The manager, Louise Hurst was registered with the Commission for Social Care Inspection in January 2006. Since her employment many improvements have been made, particularly in care planning. She has completed five units of the Registered Managers Award but has had to change college location. The Hermitage employs one deputy and she has achieved the Registered Managers Award and NVQ 4 in care. She and the manager report that they work well together. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 23 Staffing difficulties were identified throughout this visit and there appear to be factions working against each other. The staff group as a whole need to be very clear about what is acceptable practise and place emphasis on respect, residents’ choice and flexible daily routines. To remedy this situation, the manager has re-arranged the rotas so that all staff work a mixture of shifts, which will hopefully create one solid team. Implementation of an individual staff supervision system should also improve the situation and give the manager better opportunity to guide the staff. Staff report that team meetings are now being held. Staffing ratios in The Hermitage are high. However, as previously identified within the report these resources are not being used to best advantage and the manager needs to assess the daily routines and allocate staff to specific roles. The manager must ensure that she knows what is happening on each shift and discourage institutionalised practice. The manager reports being well supported by the Trustees and she has recently undergone a personal appraisal of her role, which includes target setting. The manager has started to initiate a quality assurance system; residents’ meetings have been held and questionnaires sent out. This information is to be collated and an action plan devised. The manager was reminded that quality assurance includes staff supervision. The manager reported that questionnaires are to be sent to residents’ families and that the views of staff are also to be sought. The trustees and the manager have a history of cooperation and compliance with the Commission for Social Care Inspection. Monthly visits are undertaken by the Responsible Individual, who has recently changed and reports are sent to the Commission for Social Care Inspection. The manager notifies the Commission of the elements listed in Care Homes Regulation 37, as required. Generally families assist the residents with their finances, however two are assisted by the home. It is recommended that the same robust system be introduced to record all residents’ financial transactions and that double signatures be obtained. These should be written into a procedure and the Commission for Social Care Inspection informed. A random selection of the maintenance records were seen and evidence that appropriate emphasis is placed on Health and Safety of the environment. As previously identified, this should be expanded to ensure that the residents are able to maintain their independence and access the external grounds safely. The manager was informed of the need to undertake individual assessments on the residents for fire evacuation purposes. Fire training for staff is due. Health and Safety training is provided to staff at the correct frequencies, including manual handling, first aid and food and hygiene. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 3 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 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 OP3 Regulation Requirement Timescale for action 01/07/06 2 3 OP7 OP8 4 OP9 5 OP12 13 (4c) 13 Risk assessments including (5) manual handling and falls risk assessments require further development and expansion. Previous Requirement 12 (2) Care plan information must also be available for respite service users. 12 (1, 5) The manager must ensure that all staff follow the guidance given by the health professionals, which should be included in the relevant section of the care plan and that care staff be available at all times to assist and/or supervise the service users. 13 (2) The manager must ensure that controlled medication is appropriately checked, recorded and monitored. 16 (2n) Day to day activities need to be expanded. Previous Requirement 01/07/06 01/07/06 25/05/06 01/07/06 6 OP14 12 (3) In order to promote personal autonomy and choice, service users must be enabled to take DS0000005013.V290108.R01.S.doc 01/07/06 The Hermitage Version 5.1 Page 26 7 OP14 12 (3, 4) 8 9 OP16 OP20 22 (5) 23 (2a, n, o) 10 OP20 23 (2i) 11 12 13 OP22 OP30 OP36 23 (2l) 18 (c, i) 18 (2) risks following suitable consultation and documentation. Previous Requirement The Home must examine the issue of personal autonomy and choice and how this can be further expanded and evidenced, this should include flexibility within daily routines. Previous Requirement The manager must ensure that all residents have a copy of the complaints procedure. The Home must ensure safe entrance and egress to the Home and access to the grounds and should consider fitting suitable ramps and handrails. Should the home expand suitable facilities must be provided for service users to meet privately with their visitors, which is separate from their own bedrooms. Previous Requirement Should the home expand room must be provided for the storage of equipment. New staff should receive induction training. All staff should be appropriately supervised. Previous Requirement 01/07/06 01/07/06 01/08/06 01/10/06 01/10/06 01/07/06 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that a ‘hard copy’ of individual care plans also be available and a system introduced for maintaining its currency. DS0000005013.V290108.R01.S.doc Version 5.1 Page 27 The Hermitage 2 3 OP9 OP12 4 5 6 7 8 9 OP15 OP16 OP16 OP21 OP27 OP35 It is recommended that controlled medication be checked and stock control recorded every night. The manager should also monitor this on a regular basis. It is recommended that staff be allocated to spend more time with the residents, which could be used to undertake activities with groups and/or individuals or accompany residents into the local community. It is suggested that some staff eat their meal with the residents, rather than in the staff room. It is recommended that the individual issue of being able to leave and enter the Home be addressed as a complaint and investigated fully. It is recommended that manager introduce a complaints log, which includes details of any investigation undertaken, subsequent action and the outcome. It is recommended that the downstairs bathroom be given priority in the maintenance programme. It is strongly recommended that staff take staggered breaks in order that there are care staff available to the residents at all times. It is recommended that the same robust system be introduced to record all residents’ financial transactions and that double signatures be obtained. These should be written into a procedure and the Commission for Social Care Inspection informed. The Hermitage DS0000005013.V290108.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000005013.V290108.R01.S.doc Version 5.1 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. 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