Inspection on 26/02/08 for The Hermitage

This inspection was carried out on 26th February 2008.

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

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

Other inspections for this house

The Hermitage 07/01/09

The Hermitage 24/05/06

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 Rachel Davis Announced Inspection 26th February 2008 10:30 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 The Hermitage DS0000005013.V360194.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. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 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 manager@uttoxeterhermitage.co.uk 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.V360194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2007 Brief Description of the Service: The Hermitage is a large detached Victorian house has been extended to provide accommodation for 12 ladies, six of who may have a physical disability 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 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 two double and eight 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. The lounges, dining areas and all other indoor and outdoor facilities are adequate and considered fit for purpose but would not necessarily meet with today’s relevant guidance. Fees charged range from £377- £386 per week. Full information on costs is available within the homes Statement of Purpose The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate outcomes. We, the commission, carried out this announced inspection over 5 hours and we used the National Minimum Standards for Older People as the basis for the inspection. This was a ‘Key’ inspection, during a ‘Key’ all the core Standards are assessed. The Hermitage is registered with the Commission for Social Care Inspection to provide care to 12 ladies. The manager of the home has decommissioned one other bedroom therefore there is capacity for 11 ladies presently. The home does not offer intermediate care but can provide short term or respite care. During our visit we looked at how people were admitted to the service and the information they had to make a decision. We looked at the life people are able to lead and whether their health and personal care needs are being met. We also looked to see whether people who use the service are being protected and the arrangements the service had for listening to what people thought about The Hermitage. During the visit we met and spoke to a number of people living in the home, some visitors and members of staff. Observations were made of staff and resident interaction around non-personal care tasks and during lunchtime whilst the medication was administered. We also looked round the home to see the standard of the accommodation. Potential service users and their representatives are able to gain information about the service from the Statement of Purpose. Our inspection reports can be obtained directly from the provider or are available on our website at www.csci.org.uk What the service does well: The home provides a good standard of residential care, for ladies with a physical disability or dementia related conditions, in a safe, clean and homely atmosphere. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 6 Residents and relatives are complimentary about the staff and the care they receive. They also confirmed that they are treated politely and respectfully at all times. Responses received included: ‘I’m very happy thank you.’ ‘Everybody is very kind’. ‘Very good’ ‘I have every confidence in the home.’ ‘They look after people really well.’ There are good assessment procedures at The Hermitage which have continued to improve, people are given opportunities to visit the home and have a short stay before making any final decisions. Health needs are closely monitored and access to other health professionals is arranged as required, emotional needs appear to be addressed with care and sensitivity. One visiting professional stated: ‘ We receive appropriate referrals and the staff act promptly.’ When we spoke to people living at The Hermitage they said that they liked the care staff and found them to be very caring, we saw staff had good relationships with the people who use the service. The management of residents’ monies is robust and safe. We looked at the way the service recruited staff, we found that overall their procedure was protecting the people who use the service. People who use the service know how to complain, the procedure offered contains all the information necessary. What has improved since the last inspection? The homes environment has improved, extra storage has been made available and the corridor area outside the office has been made safe by levelling the floor and adding a carpet strip. The manager has liaised with the fire officer and ensured The Hermitage is complying with the Regulations and thus ensuring a safe environment for the people who use the service. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 7 The manager has ensured that individuals are consulted about activities and stimulation within the home. A record of activities undertaken is now kept and plans of care offer information as to the individuals’ preferences and choices. Risk assessments have improved and those seen offered information on how to manage the risk, this ensures everyone understands how and why decisions have been reached. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good assessment procedures in place, people who use the service receive information to confirm the home is able to meet their needs. EVIDENCE: The service has developed a Statement Of Purpose and Service User Guide, these set out the aims and objectives of the home, and include information about the service, they also include the fees payable and the staffs’ qualifications. Although confirmed by the manager that the people who use the service receive a Statement of Purpose/ Service User Guide (The Hermitage have these two documents in one) there is no evidence to verify this The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 10 It is recommended that the Statement of Purpose and Service User Guide are made available in a format appropriate (where necessary) for the people who use the service, considering individual capacity and language. The home may wish to consider an audio or pictorial version. The care records were checked and contained the needs assessment as required, pre admission documentation is sound and offers appropriate opportunities for the manager to assess whether The Hermitage can meet the needs of the prospective user. It was evident the manager has assessed the needs of the resident prior to admission and a subsequent care plan has been developed, this affords staff the information necessary to provide appropriate care. The home should seriously consider operating a key worker system, this would help individuals feel comfortable in their new surroundings and enable them to ask any questions about life in the home. It will also encourage and help staff to develop a person centred approach to care. One person who had recently arrived at The Hermitage said they had settled in well and were happy. Standard 6 is not assessed, as the home does not provide intermediate care. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Each person has a plan of care but the practice of involving people who use the service in the development and review of the plan needs to be implemented. Medication systems do not always follow good practice or safe practice guidelines and require action to ensure that the residents are fully safeguarded. EVIDENCE: Care plans are in place and information within them is informative, however they are not presently person centred and the manager should seriously consider implementing a key worker system to offer a more intimate and personal approach to care delivery. Evidence is available to confirm the care plans are regularly reviewed and the manager has assured us that in future it will be with input from the person who uses the service. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 12 Daily records and daily statements are also evident with risk assessments in place where needed. Unfortunately manual handling risk assessments have not been recorded because the computer system does not allow for this, the manager will need to provide these in paper format in this instance. The manager has ensured that when a risk assessment is completed there is a management plan in place to advise staff on what to do. It would be useful to identify is this was a low, medium or high risk Staff are considered kind, sensitive and helpful, the staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care. People spoken to, both residents and visitors are positive about relationships and communication: ‘There is a flexible, consistent and caring service offered here.’ ‘The Hermitage provides me with an invaluable service and always keep me informed.’ The home understands the need to comply with the administration, safekeeping and disposal of controlled drugs but medication systems do not always follow good practice or safe practice guidelines and need some attention. The Controlled Drugs cabinet found within the home was breaching the Misuse of Drugs (Safe Custody) Regulations because it had not been attached to the wall. However, we found the recording of Controlled Drugs in the Controlled Drugs register was correct and stock levels tallied. We observed medication being administered, staff must ensure that any decision making around medication administration is undertaken with the necessary people and appropriately recorded. We saw that decisions had been made for people using the service around ‘as and when required’ medications that were not recorded in plans of care, this was discussed with the manager at the time of the inspection. We have asked the manager to confirm the medication is stored within the temperature range recommended by the manufacturer to ensure that medication does not loose potency or become contaminated, we felt the office (where it is presently stored) was a little too hot, especially as the medication trolley sits next to the central heating pipework. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Activities and stimulation are in place and people are able to maintain good relationships with family and friends and receive visitors at any time. EVIDENCE: The manager confirmed the home has an activity programme and offers a variety of activities according to preferences each day. Since the last inspection a record of activities is now held to support any decision making and verifies who enjoys what. On the day of the inspection the ladies were able to enjoy a massage, this is provided by an external therapist on a monthly basis, it was confirmed that this has become very popular. From discussion with people who use the service, and from observation of practices, individuals are able to retain control of their lives and were given opportunities to make informed decisions. Discussion with people who use the service confirmed there are no restrictions on visiting from family and friends, and observation confirmed people who use the service could come and go as they pleased. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 14 The kitchen is well maintained, it was inspected and found to be clean and tidy. All the required records for fridge and freezer temperatures, meat probing and cleaning duties were in place but not always completed, this was discussed with the cook and the manager. When we looked in the fridge and freezer we noted that there were not always dates available to confirm when food should be consumed by, There should be evidence available to confirm when opened jars, items in the freezer or any other unmarked food stuffs need to be discarded. All areas of the kitchen were clean and well presented, crockery and cutlery were of a satisfactory standard. Food supplies are plentiful and fresh fruit and vegetables are available. We noticed that people who use the service are offered an alternative meal but there was little evidence of written or visual prompts to enable people who use the service to know what was for dinner. The home should consider how this can be promoted and records of the food provided should be available to enable anyone inspecting them to determine what diet has been offered. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure and ensures the people who use the service are protected from abuse in accordance with written policies. EVIDENCE: The Commission has not received any formal complaints about the home since the last inspection, the manager is happy to promote the recording of complaints in a transparent manner and these were evident in the homes complaints log. The complaints procedure is displayed in the lounge and in the Statement of Purpose/Service User Guide. It meets with the requirements and was checked in detail during a thematic inspection held during 2007. The home should consider making the complaints procedure available in other formats and consider how people with complex conditions are able to voice any of their concerns. The home should also consider offering people other alternatives such as a suggestions box and /or a comment, compliments, grumbles book. The majority of staff have received training in the recognition of abuse and has the required policies and procedures. It is recommended the home confirms that the guidance has been reviewed in the context of the Government The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 16 guidance ‘No Secrets’, and in line with the Safeguarding Adults protocol and Guidance agreed by the Commission for Social Care Inspection (CSCI), the Association of Directors of Social Services (ADSS) and the Association of Chief Police Officers (ACPO). Presently the home does not have the updated Safeguarding policy. It is strongly recommended that the home is in receipt a copy of this policy to ensure they are aware of new procedures. The Hermitage DS0000005013.V360194.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): 19, 24 and 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Hermitage is a pleasant, clean and homely place to live. EVIDENCE: People who use the service, questionnaires, and visitors say the home is clean, warm, well lit and homely. A tour of the building was made, all the communal areas were seen as well as a random selection of bedrooms. This tour confirmed that the above statement is an accurate reflection of The Hermitage. The home is a Victorian property and does not meet with the new legislation around larger bedrooms, private meeting rooms or en suite facilities. However, every attempt has been made to make the most of the facilities they have, people who use the service are happy with their surroundings. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 18 Bedrooms were seen, and personalised, the people were happy with their private space. We discussed the fact that a number of bedroom doors do not have a suitable lock, an no- one holds a key to their bedroom, evidence must be available to confirm people who use the service have been offered an opportunity of a key to their room to promote privacy, dignity and choice. The safety of the carpet in some areas (it is ill fitting and loose) needs to be assessed for the risk it presents to the people who use the service, any action taken to minimize the risk must be recorded. The laundry area was inspected on this visit and seen to be satisfactory. Infection control measures are in place, examples of this include: paper towels, liquid soap, laundry management and personal protective clothing. The Hermitage DS0000005013.V360194.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): 27, 28, 29 and 30.Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager ensures the home is staffed at all times by a sufficient number of trained personnel. EVIDENCE: The service vets all potential staff ensuring that the people using the service are safeguarded. Policies and procedures are in place in relation to the recruitment of care staff, the agency is advised to remove ‘date of birth’ from the application form to meet with age discrimination legislation. Two written references are obtained for all staff, the carers do not start working with the people using the service until the agency has obtained the results of a Protection of Vulnerable Adults First check. The Hermitage need to ensure they follow the guidance offered on supervising staff between a Protection of Vulnerable Adults First check and a Criminal Record Bureau disclosure when necessary, this will further protect vulnerable people. An inspection of a small random sample of personnel files found that thorough recruitment practices are in place. This includes: the completion of a job application form, the uptake of a minimum of 2 references and an enhanced criminal records bureau disclosure (police check), appropriate identification, a The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 20 health declaration and a recent photograph. The manager is required to ensure the dates of when a member of staff commences and ceases employment are kept, this was not available on records for two staff on this occasion. The manager confirmed new staff complete an induction, which includes working with an existing member of staff. Unfortunately, there was not any evidence to show that this was the case, as two new staff members files did not contain the necessary documentation. We looked at some training records and noted some staff have not yet received training in the recognition of abuse, support and training must be provided for all staff in relation to Safeguarding adults to ensure staff are aware of types of abuse and neglect and can respond to an alert. The manager confirmed all other mandatory training was up to date. We are aware the service has provided some specialist training for staff and the manager is presently ensuring all staff receive training in the completion of care plans. The home should consider offering staff training in equality and diversity. The registered manager has obtained the Registered Managers Award, this is a legal requirement for managers of a care service. During the time we spent at the service we observed staff supporting people and found there were positive and engaging interactions between those people living at The Hermitage and the staff members. People who use the service said: ‘The staff are sensitive and caring.’ ‘Home from home, the staff are lovely.’ The Hermitage DS0000005013.V360194.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): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager offers leadership but this must be followed up with an appropriately supervised workforce. This will further demonstrate that it is run in the best interests of the people who use the service. EVIDENCE: When we prepared for the inspection we sent surveys to a number of people using the service and the staff . These gave us information about how the service is managed, whether people using the service are satisfied and whether the staff have the training and support required to meet their needs. The manager is qualified and has the necessary experience to run the home. Insurance is valid and the registration certificate is clearly displayed. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 22 The manager understands person centred planning but there is no evidence presently to show the translating of this theory into practice. The home should consider ways in which to evidence equality and diversity within their service. All sections of the Annual Quality Assurance Assessment (AQAA) are completed (this is a legal document and must be provided by the manager prior to an inspection.) The information gives a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would be useful to illustrate what the home has done, or how it is planning to improve. The Annual Quality Assurance Assessment gives the Commission some limited detail about the areas that still need improvement and the ways that the home plans to achieve this are very briefly explained. On this visit we did not check all maintenance records but we have been informed by the manager on the Annual Quality Assurance Assessment the dates of all required tests. Records of supervision are not evident and the manager confirmed this is still not occurring. This is a previous requirement and must take priority. The staff need to receive appropriate supervision commensurate to their role, this will confirm an informed, consistent and well managed service is provided to the people who use the service. Financial systems are in place at The Hermitage, the home does not presently deal with personal allowances but they have suitable policies and procedures in place should this be necessary. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Timescale for action 14/04/08 2 OP7 13 (4)(b)(c) 3 OP9 13(2) 4 OP9 13(2) Plans of care for people who use the service must evidence consultation with individuals or their representative to demonstrate that the plans have been agreed by the person. Manual handling risk 14/04/08 assessments need to be in place for all the people who use the service and include evidence of the service users involvement or their representative. This ensures everyone is clear on how to manage the risk whilst, where appropriate, empowering the individual to take reasonable risk. The Controlled Drugs cabinet 01/04/08 needs to be fixed to the wall in order to comply with the Misuse of Drugs (Safe Custody) Regulations. Appropriate information relating 01/04/08 to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including “when required” to ensure that DS0000005013.V360194.R01.S.doc Version 5.2 The Hermitage Page 25 5 OP15 13 6 OP19 13(4)(a) 7 OP24 16(l) 8 OP29 17(2) 9 OP30 13(6) 10 OP36 18 (2) all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. The records of fridge and freezer temperatures need to be undertaken on a daily basis, this will ensure food is being stored within the required range. Carpets and flooring within the home must be assessed for the risk they present to the people who use the service and action taken to minimize the risk. Evidence must be available to confirm people who use the service have been offered an opportunity of a key to their room to promote privacy, dignity and choice. The manager is required to ensure the dates of when a member of staff commences and ceases employment are kept. Support and training is to be provided for all staff in relation to Safeguarding adults to ensure staff are aware of types of abuse and neglect and can respond to an alert. The service must ensure that each employee receives appropriate supervision. Previous requirement not met 11/12/06 01/04/08 14/04/08 01/04/08 01/04/08 30/04/08 01/04/08 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 OP1 Good Practice Recommendations The home should develop a more user friendly Statement DS0000005013.V360194.R01.S.doc Version 5.2 Page 26 The Hermitage 2 3 4 5 6 OP1 OP4 OP7 OP9 OP9 7 8 9 OP15 OP15 OP16 10 11 12 13 OP18 OP29 OP30 OP30 of Purpose and Service User Guide to assist people who use the service with diverse and/or complex needs. It is recommended there is evidence available to confirm that the people who use the service have received the Statement of Purpose and Service User Guide It is strongly recommended that a key worker system is introduced at The Hermitage to encourage and develop a more person centred approach to care. Plans of care should be developed to evidence a person centred approach. All staff administering medication should undergo recorded periodic assessments to ensure their ongoing competency to follow the home’s procedures correctly. Confirmation should be sort to confirm medication is stored as recommended by the manufacturer, this will ensure that medication does not loose potency or become contaminated. Records of the food provided should be available to enable anyone inspecting them to determine what diet has been offered. There should be evidence available to confirm when opened jars, items in the freezer or any other unmarked food stuffs need to be consumed by. The home should offer a comments book and/or suggestions box for people who use the service or any other person entering the home. This will mean people can offer their comments anonymously if preferred. The home should ensure they have a copy of the Safeguarding of Adults policy. The home may wish to improve the content of their application form so it fully conforms to recent legislation. The home should consider offering staff training in equality and diversity. The home should consider ways in which to evidence equality and diversity within their service. The Hermitage DS0000005013.V360194.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 © 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.V360194.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!