Inspection on 29/11/05 for The Hermitage

This inspection was carried out on 29th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hermitage 28/08/07

The Hermitage 07/08/06

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 Unannounced Inspection 29th November 2005 09:30 The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 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.V265332.R01.S.doc Version 5.0 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.V265332.R01.S.doc Version 5.0 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 Oaklands NHS Trust Mrs Kim Baldacchino Care Home 14 Category(ies) of Learning disability (14) registration, with number of places The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 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. 23rd May 2005 Date of last inspection Brief Description of the Service: The Hermitage is a fourteen place residential home for people with learning disabilities, however only eleven service users live at the home at present. Some of the service users also have physical disabilities. The home is a large detached house situated in a mainly residential road in Thornton Heath, close to local shops and transport. The home is within easy reach of Croydon town centre and all its facilities. Each of the service users has their own bedroom, which is personalised to their own tastes. There is also a large dining room, communal lounge and an activities room. There is a large garden to the rear of the house, which is well used in the summer. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 09.30 am and finished at 11.30 am on a Tuesday morning. The registered manager was not present however the deputy manager ably supported the inspection process. Methods of inspection included previous inspection experience of the home, observation of contact between staff and service users and discussion with deputy manager. Records examined included Person Centred Plans, staffing records, service user questionnaires and quality assurance records, fire records, health and safety records and the homes Statement of Purpose. What the service does well: Service users are offered opportunities to engage in activities in the local community. Service users have had individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. In general service users medication is well managed to ensure maximised good health. What has improved since the last inspection? What they could do better: There were four requirements and two recommendations set at the last inspection. The deputy manager provided evidence that two of the requirements had been met however she could not provide evidence that the other two had been met and these have been re-entered with the original time scales for action. One recommendation has been reassessed and re-entered in this report as a requirement. As a result of this inspection there are now three requirements and four recommendations. The overall impression when visiting the home is that it is well organised however the home could do more to ensure that staff records and Criminal Records Bureau Checks are completed. In general information available to prospective service users is good however the homes Statement of Purpose has been under review since the last inspection. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 6 The inspector would like to thank the service users, staff and the deputy manager for their support on the day of the inspection. 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 DS0000025850.V265332.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Standards 2 and 4 were assessed as met at the last inspection. In general information available to prospective service users is good however the homes Statement of Purpose has been under review since the last inspection. EVIDENCE: At the last inspection the registered manager had reviewed the Service Users Guide and was planning to review and update the homes Statement of Purpose. A requirement was set that the manager ensure that the Statement of Purpose includes details as stated in Schedule 1 of the National Minimum Standards Care homes for Adults 18-65. The deputy manager produced evidence that the registered manager is reviewing the Statement of Purpose but was not sure if the she had completed the review. The requirement stands. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. Standards 6, 7 and 10 were assessed as met at the last inspection. Service users have had individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: A requirement was set at the last inspection that the registered manage ensure that a risk assessment is carried out for the service user who is 85 years old regarding him using the stairs and this risk assessment is kept under review. The deputy manager provided evidence that a risk assessment has been carried out and is due to be reviewed in December. The deputy manager explained that one service user had fallen down the stairs and broke her jaw the previous week. On the day of the inspection she spoke to the hospital as they wanted to send the service user home. She contacted service users care manager because she had concerns about the service user moving back to the home before appropriate assessments had been carried out around her mobility and use of the stairs. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 10 The deputy manager wanted to ensure that all risk assessments had been carried out. The deputy manager said that the service users care manager may also want to review the service users placement. All service users now have a completed Person Centred Plan. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 16. Standards 11, 12, 14, 15 and 17 were assessed as met at the last inspection. Service users are offered opportunities to engage in activities in the local community. EVIDENCE: The deputy manager stated that most of the service users have bus passes and two service users who use wheelchairs sometimes use the Computer Cabs firm for transport. The home has two minibuses. The deputy manager stated that service users frequent the local cafes, hairdressers, barbers, shops and cafes. It was noted at the last inspection that service users also go to the cinema in Streatham, bowling in Purley Way, the Saturday Club, Monday Club, one service user goes to the over Sixty-five Lunch Club and an Aroma Therapist visits the home on Thursday afternoons. During the course of the inspection it was noted that staff treated service users with dignity and respect. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20. Standard 19 was assessed as met at the last inspection. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. In general service users medication is well managed to ensure maximised good health. EVIDENCE: Medication is stored in a locked cabinet in the dining area. Medication administration records examined were accurate and up to date with the exception of one occasion when a member of staff did not sign to indicate that a service user had been administered medication. It is recommended that the registered manager discuss the homes medication administration procedure with the whole staff team. Service users medication records also contain 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. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 13 Service users Person Centred Plans indicate their level of support needs and how the service user prefers personal care to be carried out. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. Standards 22 and 23 were assessed as met at the last inspection. The home has appropriate complaints and adult protection procedures procedure in place. EVIDENCE: The deputy manager stated that the registered manager sent copies of the homes complaints procedures to all service users relatives as recommended at the last inspection. The deputy manager said that she posted them off. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Standards 25, 26 and 28 were assessed as met at the last inspection. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. EVIDENCE: The registered manager has obtained new settees and chairs for the living room as required at the last inspection. 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. During the inspection it was noted that some staffing information was stored in the dining room area. It is recommended that all staffing information is stored in the homes office. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35. Standards 31, 32, 33 and 36 were assessed as met at the last inspection. The employer’s responsibility to undertake Criminal Records Bureau Checks for staff is still inconsistent. The home should obtain all the information required in Schedule 2 National Minimum Standards for all members of staff employed in the home thus ensuring that service users are safeguarded so far as reasonably practicable from risk of harm or abuse. EVIDENCE: A requirement was set at the last inspection that the registered manager must write to the Commission for Social Care Inspection when she receives the other five members of staffs Criminal Records Bureau Checks and arrange a date for these to be inspected. The registered manager has yet to contact the Commission. The deputy manager produced her own Criminal Records Bureau Check that was outstanding at the last inspection however she was not sure if the others had been obtained. The deputy manager was advised to ask the registered manager to contact the Commission on her return to work so as to clarify the situation as regards the four outstanding Criminal Records Bureau Checks. The requirement stands. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 17 It was recommended at the last inspection that staff files should include a recent photograph. Staff files examined did not have a recent photograph. The deputy manager stated that pictures had been taken but not yet developed and placed in staff files. The registered manager must ensure that all the information required in Schedule 2 National Minimum Standards for all members of staff employed in the home is kept on file. The deputy manager explained that the Surrey and Borders NHS Trust is currently implementing a programme “Agenda For Change”. Part of the programme includes the “Knowledge Skills Framework” that will form the basis for the appraisal system for the Trust. She said that this might come into action in the coming year. The deputy manager supported the inspection process where she could but was not sure where to look for some information. It is recommended that the registered manager supports the deputy manager to acquaint yourself with the homes administration systems. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. Standard 37 was assessed as met at the last inspection. The home appears to be well run and well managed. Appropriate quality assurance and quality monitoring systems are in place so that the views of the service users and their representatives are considered about the running of the home. EVIDENCE: The deputy manager stated that the home had completed a service users survey and service users relatives have been invited by the Surrey and Borders NHS Trust to complete a questionnaire and return it to the trust for evaluation. The deputy manager said that feedback had been returned to the home but she was not able to produce this on the day of the inspection. There was also evidence that regular regulation 26 visits are carried out at the home and an Annual Quality Audit had been carried out at the home on the 31/03/05. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 19 Evidence was provided for Portable Appliance Testing 13/04/05, Landlords Gas Safety Certificate 28/04/05 and Legionella Testing had been carried out. The tests for Portable Appliance Testing and Legionellas had been requested by the home on these dates however testing was completed some time afterwards and receipts have been signed by staff that the work had been carried out. It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. There is evidence that the fire alarm system is checked on a regular weekly basis. The Fire officer visited the home on 04/12/04 the follow up report stated that the premises was found to be satisfactory as far as fire safety matters were concerned. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Hermitage Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000025850.V265332.R01.S.doc Version 5.0 Page 21 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. Standard YA1 Regulation 4(1) Requirement Timescale for action 31/08/05 2. YA34 19 (1) b 3. YA34 19 (1) b The manager must ensure that the Statement of Purpose includes details as stated in Schedule 1 of the National Minimum Standards Care homes for Adults 18-65. This requirement is unmet from previous inspection 23rd May 2005. The registered manager must 31/08/05 write to the Commission for Social Care Inspection when she receives the other five members of staffs Criminal Records Bureau Checks and arrange a date for these to be inspected. This requirement is unmet from previous inspection 23rd May 2005. The registered manager must 31/01/06 ensure that all the information required in Schedule 2 National Minimum Standards for all members of staff employed in the home is kept on file. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 22 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 YA31 YA20 YA24 YA42 Good Practice Recommendations It is recommended that the registered manager supports the deputy manager to acquaint yourself with the homes administration systems. It is recommended that the registered manager discuss the homes medication administration procedure with the whole staff team. It is recommended that all staffing information is stored in the homes office. It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Hermitage DS0000025850.V265332.R01.S.doc Version 5.0 Page 24 - 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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