Inspection on 28/08/07 for The Hermitage

This inspection was carried out on 28th August 2007.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hermitage 07/08/06

The Hermitage 29/11/05

The Hermitage 23/05/05

The Hermitage 09/09/04

The Hermitage 21/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 O`Hara Key Unannounced Inspection 28th August 2007 10:30 The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 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 DS0000025850.V348152.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 Adults 18-65. 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 DS0000025850.V348152.R01.S.doc Version 5.2 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 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) Surrey and Borders Partnership NHS Trust Mrs Kim Baldacchino Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 7th August 2006 Date of last inspection Brief Description of the Service: The Hermitage is a ten place residential home for people with learning disabilities. Some people 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 person 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 DS0000025850.V348152.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 10:30am and 1pm on a Tuesday morning/afternoon. The registered manager was not present on the day of the inspection so it was not possible to examine some records. The deputy manager provided evidence where she could. The deputy manager contacted the area service manager to advise that an inspection was taking place. Methods of inspection included a tour of the premises, observation of contact between staff and people who use the service and discussion with the deputy manager. Records examined included the homes Statement of Purpose and Service Users Guide, care plans, person centred plans, risk assessments, complaints, adult protection, training, medication, and health and safety. Requirements and recommendations from the previous inspection were also discussed with the deputy manager. What the service does well: What has improved since the last inspection? The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 6 The home is improving how it communicates with people who use the service, there are pictorial menus and a pictorial staffing rota indicating staff on shift and activities for the day. Staff attended challenging behaviour and working and communicating with people with learning disabilities workshops. Staff attended training on Person Centred Planning. New furniture has been purchased and flooring has been replaced in the dining area. What they could do better: There were four requirements and seven recommendations set at the last key inspection. Some of the requirements have not been fully met. As a result of this inspection there are six requirements and five recommendations. The home could make sure that peoples individual risk assessments are kept under review. The home could make sure that the practice of wedging open peoples bedroom doors is eliminated. When planning staff training the home could take into account that one person is registered blind, some people have epilepsy, some people have physical disabilities and some people have elderly needs. The home could make sure that night time staff receive supervision and training on the same frequency as daytime staff. Some staff still needs to attend training on adult protection. The home could consider redecoration of the communal areas in particular the skirting boards on the ground floor. The Surrey and Borders NHS Trust need to make sure that Regulations 26 visits are carried out at the home in order form an opinion of the standard of care provided. This will ensure that people who use the service can be confident that the home is appropriately managed. The inspector would like to thank the people who use the service, the staff and the deputy manager for their support in the inspection process. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 7 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 DS0000025850.V348152.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who plan to use the service and their representatives with the information they need so that they can make an informed decision about whether or not to use the service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: The home has a Statement of Purpose and Service Users Guide (Residents Handbook). The Statement of Purpose and Residents Handbook is available to all in pictorial format and kept up to date with detailed information on the services and support provided by the home and its staff and how the service will meet the individuals needs. No new service users have moved into the home since the last inspection, there are (10) people living at the home at present. The Surrey and Borders NHS Trust has an Admission Procedure, that states that people are only admitted to the home once a full assessment has been completed by an appropriate person (usually a care manager) and sent to the The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 10 home, along with any other information about the person needs. The person’s family is also involved, if it is appropriate. The Commission has revised its procedures for setting categories as conditions in keeping with the principles of Inspecting for Better Lives. It is no longer required that providers should seek a variation to support adults over the age of 65. The condition to allow person over the age of 65 to live at the home will be removed and a new certificate will be sent to the home. The primary care need of all of the people who use the service is learning disabilities. However some people also have a physical disability and use wheel chairs. It is recommended that the homes Statement of Purpose be updated to reflect that the home supports people with physical disability and some people with elderly needs. The deputy manager stated that the fee charged at the home is £55,531.00 but this is currently under review. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have person centred plans that include information on their needs, likes and dislikes. People have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. However some of these risk assessments have not been kept under review. EVIDENCE: Two people personal files were examined at random. Both people had Person Centred Plans and both had had their care plans/placements reviewed by a care manager from their placing authority. Person Centred Plans included headings such as what matters to me, things I enjoy, my future, things to do in order to keep me healthy, my dreams, a relationship circle and how I communicate. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 12 It was noted that one persons risk assessments had been kept under review however the other persons risk assessments had not been reviewed on the agreed date in July 2007. It is recommended that all people who use the service have their risk assessments kept under regular review. The deputy manager stated that five members of staff had attended training on Person Centred Planning. These staff are due to complete the last part of the training, Maps and Pathways, that will give them a better idea of how to support people who use the service with their Person Centred Plans. There was evidence that the home is improving how it communicates with people who use the service, there are pictorial menus and a pictorial rota indicating staff on shift and activities for the day. The deputy manager provided evidence that all staff attended a communication workshop, challenging behaviour workshop and working and communicating with people with learning disabilities. The deputy manager stated that residents meetings take place on a regular three monthly basis. The deputy manager could not locate these on the day of the inspection however these were observed at the last inspection visit. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are offered a varied programme of social and leisure activities that reflects their individual interests. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to people who use the service. EVIDENCE: Five people attend Geoffrey Harris House day service. The home has an activities coordinator who facilitates activities within the home on Wednesdays, Thursdays and Fridays. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 14 The deputy manager stated that one person goes to Adult education for cookery classes, one person is on the waiting list for this course and one person is looking at attending a different daycare facility. The deputy manager stated that people frequent the local cafes, hairdressers, barbers, shops and cafes, a Saturday Club, Monday Club and an Aroma Therapist visits the home on Thursday afternoons. The deputy manager stated that three people are going on holiday to Barcelona in September, two other are going to Spain, and the remaining people are currently planning their annual holiday. Most people have bus passes and two people who use wheelchairs sometimes use the Computer Cabs firm for transport. The home has two minibuses and people regularly go on day trips to Brighton and the coast. It was observed that one person likes John Wayne. In line with the homes person centred approach he has decorated his room around this topic. He has a set of saloon doors leading to a living area just off his bedroom, he has a television, DVD player, John Wayne and other cowboy DVDs, posters of John Wayne, Clint Eastwood and himself in a cowboy outfit, toy guns and other cowboy and Indian paraphernalia. People are able to keep in contact with their relatives. The home has an open visitors policy and staff just ask that people phone ahead of any visit to check that the person is at home. Staff supports one person home so that he can spend the day with his parents. All other residents in touch with family through invitations to PCP meetings, BBQs, Christmas parties, Birthdays and music events. The homes menus are employed on a four-weekly rota basis. The menus reflect choices agreed at three monthly residents meetings and are changed seasonally for summer and winter, the menu also takes into account individual’s dietary needs. The home has sought the advice of the dietician for some people and appropriate guidelines are in place. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The arrangements for meeting the health care needs of people who use the service are good and people receive personal support in the way they prefer. EVIDENCE: All people who use the service are registered with a General Practitioner. People are able to access community health facilities such as opticians, chiropodist and district nurses as required. Person Centred Plans indicate people’s level of support needs and how they prefer personal care to be carried out. Medication is stored in a locked cabinet in the dining area. Medication administration records examined were accurate and up to date. The medication folder contained a medication profile, photographs and guidelines for the administration of as required medication. The deputy manager provided evidence that all medication is checked and balanced on Sundays. Three people have been diagnosed with epilepsy. The medication folder contained an epilepsy care plan for each person diagnosed with epilepsy. The The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 16 care plan included a description of typical seizures, guidance for staff to follow, a rectal diazepam treatment plan and a seizure chart. The deputy manager stated that epilepsy training was covered in PRN training but records show that only three members of staff attended PRN training in 2006/7. The registered manager must ensure that all members of staff attend training or refresher on epilepsy. It is recommended that all staff attend training on the assessed needs of individuals living at the home, planned training should take into account the fact that one person is registered blind, some people have physical disabilities and some people have elderly needs. The deputy manager stated that medication awareness training has been booked for non-medication givers. This training will take place on the 3rd of September. The home has the support of a pharmacist for advice; the pharmacist visited the home in July 2007. The registered manager stated in the homes Annual Quality Assurance Assessment that this was a positive inspection and the pharmacist had no concerns with the administration of medications within the home. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has an appropriate complaints procedure. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure that people are so far as reasonable practicable protected from abuse however unless all staff are trained on adult protection there is the risk that people will not be protected in a consistent manner from abuse. EVIDENCE: The home has an appropriate complaints procedure. The deputy manager stated that there had been no complaints raised with the home since the last inspection. The complaints procedure is completed in a pictorial format for the benefit of some people who use the service. A requirement was set at the last inspection that all members of staff attend adult protection training. Three members of staff attended adult protection training since the last inspection. The deputy manager stated that other members of staff have applied for the training and are waiting dates. This requirement has not yet been met in full however there is evidence that the service are actively seeking to achieve this. The deputy manager stated that the home had forwarded a copy of the homes complaints procedure to people’s relatives as recommended at the last inspection. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 18 The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home is suitable to meet the needs of the people who live there, comfortable and in reasonable decorative order however the practice of wedging open peoples bedroom doors could leave people at risk in the event of a fire. The home was clean and free from offensive odours throughout. EVIDENCE: It was observed that one persons bedroom door was wedged open. The deputy manager stated that she had no idea why the door was wedged open and closed the door immediately. The registered manager must make sure that practice of wedging open peoples bedroom doors must be eliminated. New furniture has been purchased and flooring has been replaced in the dining area. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 20 The home has a large garden with patio and good quality garden furniture. People spoken to on the day of the inspection said that they liked to sit in the garden when it was sunny. People’s bedrooms have been decorated to their own personal choices. One person said that she had a new bed in her room. On the day of the inspection the premises was clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Skirting boards on the ground floor have been scratched by wheelchair use. It is recommended that the registered manager consider redecoration of the communal areas in particular the skirting boards. The home employs a domestic member of staff who cleans the home whist staff support and encourage people who use the service to do the daily cleaning chores. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home could do more to make sure that all members of staff receive appropriate training and regular supervision so as to ensure that people who use the service benefit from having a consistent approach to their needs. EVIDENCE: The registered manager was not present on the day of the inspection so it was not possible to gain access to staff personal files. It is recommended that the registered manager contact the Commission when all Criminal Records Bureau Checks are available in the home for inspection. The home is staffed with a registered manager, deputy manager, eleven 3 support workers and one domestic. The registered manager is a Registered Nurse and holds a Registered Managers Award and NVQ Level 4 in Care. The Deputy manager aslo has a nursing qualification. The vast majority of staff holds NVQ level 2 or NVQ level 3 qualifications. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 22 A requirement was set at the last key inspection that the registered manager must ensure that all members of staff receive supervision at least six times a year. Supervision records indicated that the registered manager is on course to meet this requirement however it was observed that nighttime staff had one supervision session this year. This requirement has not yet been met. The registered manager must ensure that nighttime staff receives supervision at least six times a year. Staff training records indicated that the majority of staff had attended mandatory training sessions on moving and handling, fire safety, health and safety, first aid, food hygiene and medication. It was observed that night time staff had not attended training on the same frequency as daytime staff. The registered manager must ensure that night time staff attend all mandatory training and training required to meet the assessed needs of people who use the service. The deputy manager stated that all members of staff are undergoing the Surrey and Borders NHS Trusts appraisal system “Knowledge and Skills Framework”. The “Knowledge and Skills Framework” includes a performance development plan. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home appears to be well run and well managed however the registered providers, the Surrey and Borders NHS Trust, need to ensure that Regulations 26 visits are carried out at the home in order form an opinion of the standard of care provided. This will ensure that people who use the service can be confident that the home is appropriately managed. EVIDENCE: The registered manager has managed The Hermitage for three years. She is a Registered Nurse Learning Disabilities and has completed the Registered Managers Award. She is currently completing NVQ assessors Units A1 and A2. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 24 It is no longer a requirement under the Care Homes Regulations that regulation 26 reports are sent to the Commission unless it is requested, however copies of the reports must be available in the home for inspection. The deputy manager produced copies of regulation 26 visit reports for February, March, April and May 2007. She stated that regulation 26 visits had not been carried out by the Trust in June and July. The registered providers, the Surrey and Borders NHS Trust must ensure that regulation 26 visit are carried out at the home and send copies of the reports to the Commission. The deputy manager stated that people who use the service and their relatives had recently completed questionnaires in order that they could feedback about the service. The deputy manager stated that feedback had been positive but could not locate this information on the day of the inspection. As recommended at the last inspection staff now sign and date the receipts when the works department has carried out testing or other maintenance work at the home. Portable Appliance Testing was carried out at the home on the 23/05/07, legionellas testing was carried out on the 27/06/07 and a Landlords Gas Safety Certificate was produced for the 02/08/07. The homes fire alarm system is checked on a regular weekly basis and full fire evacuations took place in February and June 2007. The registered manager carries out regular three-month fire safety audits, portable fire equipment was checked on the 21/06/07. The home has an up to date fire safety risk assessment. The London Fire & Emergency Planning Authority visited the home in February and August 2007 to offer advice on fire safety. The majority of staff has attended fire safety training. The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 25 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. 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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 26 Yes. 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. 2. Standard YA23 YA36 Regulation 13 (6) 18 (2) Requirement The registered manager must ensure that all members of staff attend adult protection training. The registered manager must ensure that all members of staff including night time staff receive supervision at least six times a year. The registered manager must ensure that all members of staff attend training or refresher on epilepsy. The registered manager must ensure that night time staff attend all mandatory training and training required to meet the assessed needs of people who use the service. The registered providers, the Surrey and Borders NHS Trust must ensure that regulation 26 visit are carried out at the home and send copies of the reports to the Commission. The registered manager must make sure that practice of wedging open peoples bedroom doors must be eliminated. Timescale for action 31/10/07 31/10/07 3. YA20 18 (1) c (i) 18 (1) c (i) 31/10/07 4. YA32 31/12/07 5. YA39 26 (2) 31/08/07 6. YA42 23 (4) 28/08/07 The Hermitage DS0000025850.V348152.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA9 YA34 YA1 YA20 Good Practice Recommendations It is recommended that the registered manager keep peoples risk assessments reviewed and updated. It is recommended that the registered manager contact the Commission when all Criminal Records Bureau Checks are available in the home for inspection. It is recommended that the homes Statement of Purpose be updated to reflect that the home supports people with physical disability and some people with elderly needs. It is recommended that all staff attend training on the assessed needs of individuals living at the home, planned training should take into account the fact that one person is registered blind, some people have physical disabilities and some people have elderly needs. It is recommended that the registered manager consider redecoration of the communal areas in particular the skirting boards. 5. 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