Inspection on 28/02/06 for The Hermitage

This inspection was carried out on 28th February 2006.

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

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

Other inspections for this house

The Hermitage 16/05/07

The Hermitage 05/07/05

The Hermitage 31/01/05

The Hermitage 27/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Hermitage 6-12 St Mary`s Street Whittlesey Cambridgeshire PE7 1BG Lead Inspector Alison Hilton Unannounced Inspection 28th February 2006 13:05p 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 DS0000015194.V278777.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 DS0000015194.V278777.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Hermitage Address 6-12 St Mary`s Street Whittlesey Cambridgeshire PE7 1BG 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) 01733 204922 01733 753705 Mr Peter John Thory Mrs Judy Maria Wilson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: The Hermitage is a privately owned care home providing personal care and accommodation for up to 24 older people. Accommodation is provided in 16 single and 4 shared bedrooms. Whilst service users may have a range of physical disabilities, such as the need for wheelchairs, the home does not offer specialised care for people with dementia. The home is situated in the centre of Whittlesey, within easy reach of the shops and local library. The main entrance opens onto a large car park; a second entrance opens onto St. Marys Street. The home is on two floors, with communal rooms and some bedrooms on the ground floor. Other bedrooms are on the first floor, which is accessed by a shaft lift or stairs. Staffing is provided by a team of care staff who are supervised by the manager and her deputy. Staff are on duty overnight to provide assistance to those who need it. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Tuesday 28th February 2006 between the hours of 13:05 and 15:45. One inspector spoke to residents, saw the ground floor rooms, spoke to the deputy manager and made an inspection of resident files and other documentation. What the service does well: What has improved since the last inspection? 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 Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 6 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 DS0000015194.V278777.R01.S.doc Version 5.1 Page 7 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 The home adequately and appropriately assesses the needs of prospective residents to ensure these can be met. EVIDENCE: Pre-admission assessments were seen on the files inspected. These were comprehensive and contained all the necessary information for a decision to be made about prospective residents suitability for the care the home could provide. The home does not provide intermediate care. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 8 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): 7,9,11 The home was able to demonstrate that care plans and risk assessments are completed on residents within a reasonable timescale. Procedures to ensure medication is being safely administered are in place. EVIDENCE: The care plans were adequate and contained all the necessary information for care staff to be able to meet the needs of those in their care. The home has recently had a change in the supplier of the monitored dosage system and the new suppliers will not put PRN medication or temporary medication in the dossett boxes. This has left the home with many boxes and bottles containing these medications. It was discussed with the manager and deputy manager that the record for administered medication that is taken when necessary (PRN) needs to include when the course of tablets was started. This would ensure that when an audit takes place, the number of tablets in the box or bottle could be linked to the Medication Administration Record (MAR) sheet immediately without back tracking to when the medication was first prescribed. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 9 Care staff were observed when talking to residents and they were respectful but friendly. Residents all said that the staff were wonderful and kind. There was a lovely atmosphere within the home and banter between the residents and staff was a pleasure to hear. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 10 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): 12,13,15 The home provides sufficient variety of activities to ensure all residents have the opportunity to participate. EVIDENCE: Residents said that there was something going on every day. It was evident they chose whether to attend the activities or not as during the inspection an entertainer was in one lounge and several residents chose to remain in a separate lounge, but listened to the music from there. One resident went to her room to have a lay down. One resident commented that she liked to go to her room and write letters or read, others said they liked to get in the garden when the weather was warm, others said staff sometimes took them to the library. They commented that someone regularly comes round selling toiletries and sweets etc and she had been yesterday. A hairdresser calls twice a week and the chiropodist and optician also come to the home. Residents said they had lots of personal visitors come to the home. Some arrived during the inspection and they were welcomed and provided with tea and biscuits. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 11 Residents confirmed that they could choose when to get up and go to bed. They choose what to have at mealtimes and where they have them and that the food was very good. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 12 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): None of the standards in this section were inspected. EVIDENCE: The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 13 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): 19,20,24,26 The home provides safe, homely and comfortable surroundings for residents. EVIDENCE: The home is close to the centre of Whittlesey, allowing access to the shops and other local amenities. The home is well maintained and pleasantly furnished throughout. The quality of furnishings and fittings is good creating a pleasant environment for residents and visitors. The garden will provide residents with an attractive area in which to sit when the weather permits. There is a CCTV camera in the car park to increase the security of the home. The front door of the home is kept locked and visitors must ring the bell for staff to allow entry to the home. There is a visitor’s book, which is signed by all visitors to the home. There were no unpleasant odours when the inspector toured the home. Residents said their rooms were cleaned each day. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 14 The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 15 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): 30 The number of staff on duty and qualifications they have ensure the residents needs can be met. EVIDENCE: There had been no new staff start at the home since the last inspection so no staff files were inspected. Staff do receive training some of which is provided in house. A training record is kept, but some training needed to be updated. The manager was aware and has this in hand. There were three staff on duty at the time of the inspection as well as the deputy manager. Residents said staff provided the care they needed. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 16 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): 32 The home is being managed in an open and friendly way with evidence of leadership and guidance to ensure residents receive consistently high levels of care. EVIDENCE: The residents were happy to discuss issues with staff and on the day of inspection the deputy manager was asked by a resident to ensure I spoke to her. The resident in question only had positive things to say about the home and its staff, but it was evident that the home had an open door policy and acted on the requests of the residents. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 17 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 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X X X X The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The registered person should ensure that the record for administered medication that is taken when necessary (PRN) needs to include when the course of tablets was started. This would ensure that when an audit takes place, the number of tablets in the box or bottle could be linked to the Medication Administration Record (MAR) sheet immediately without back tracking to when the medication was first prescribed. The Hermitage DS0000015194.V278777.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 DS0000015194.V278777.R01.S.doc Version 5.1 Page 20 - 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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