Inspection on 05/07/05 for The Hermitage

This inspection was carried out on 5th July 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 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 28/02/06

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 Marys Street Whittlesey Cambridgeshire PE7 1BG Lead Inspector Matthew Bentley Unannounced 05 July 2005 @ 10:00 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 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 I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Hermitage Address 6-12 St Mary`s Street Whittlesey Cambridgeshire PE7 1BG 01733 204922 01733 753705 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31 January 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. Mary’s 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 I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 2.5 hours and took place on 5th July 2005 between 12.00 and 14.30. The inspection was carried out by one inspector who spoke to a number of service users and staff. The inspection also included reading documents, speaking to management, and a tour of the building. 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 I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 standard(s) 3 & 4 Suitable measures are taken to ensure that potential service users’ needs are fully assessed prior to their moving into the home and the service is able to meet the needs of older people. EVIDENCE: If a person is interested in moving into the home, the manager or her deputy visits the person concerned and meets with family members and any professionals who may be involved, so that as much information about the person’s needs as possible is obtained. Residents’ files had within them the information that had been gathered on each person’s needs, including preadmission assessments and details of the person’s social histories, hobbies and interests. Staff are experienced and competent and have a good level of knowledge about the general needs of older people and the people living at the home specifically. Aids and adaptations are available to help staff to meet service users’ needs, and discussions with staff and residents indicated that the home was capable of meeting the needs of older people. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 The system of care planning gives a good description of what help each person’s needs and how that assistance should be given so that staff can be clear about what they need to do. Arrangements are in place to ensure each service user receives input from relevant professionals to ensure each person’s health needs are met. Personal care is given sensitively so that individuals’ dignity and privacy are maintained. Procedures for managing service users’ medication are satisfactory and were being properly followed, so that medication is safely administered. EVIDENCE: Care plans relating to 4 residents were seen and showed the action required to meet their assessed health, personal, and social care needs including hobbies, interests, personal histories and likes and dislikes. The plans have been reviewed on a monthly basis and updated to show any changing needs or goals. The deputy manager said that working relationships with the GPs, District Nurses, and other people working in the health service were good, and arrangements had been made for individuals to receive regular dental and The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 9 eyesight checks. Private chiropody services are available to people who need them. At the time of the inspection no resident had a pressure sore. The home uses a pre-dispensed monitored dosage system for administering medication; training is provided by the local pharmacist. Records relating to the management of medication were examined and were found to be in order. Residents spoken to said that they felt their privacy and dignity were respected and staff used the names that they preferred. Care staff were seen talking with service users whilst helping them walk from one place to another and at lunchtime; the way they spoke was respectful and polite. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 The range and frequency of organised activities is good, and staff provide appropriate support to facilitate contact with family and friends. Residents are encouraged to make choices about their lives and are encouraged to maintain their independence. Dietary needs are well catered for, with a balanced and varied selection of food available to meet residents’ individual tastes and choices. EVIDENCE: The deputy manager is responsible for organising activities in and around the home, and she produces an in-house magazine, which is given out every three months. The magazine includes personal histories of new residents and other information that may be interesting to residents and relatives. A trolley is taken round each week from which people can buy personal items such as toiletries and sweets. A range of activities is organised and is clearly advertised on notices in the main corridor and elsewhere. Activities that people do in is recorded, so that no one who wants to be involved is left out. The home has a residents ‘comforts fund’ that is used to cover the cost of transport to events and to pay any admission charges and for a meal out. Recent, or forthcoming activities included quiz nights, numerous musical events, and trips out to the seaside and to wildlife centres. A fund-raising car boot sale is also taking place; this is popular with residents, relatives, and the people of the town. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 11 Relatives and friends are welcome to visit at any time, although it is preferred if they avoided visiting at mealtimes. Information about visiting is included in the home’s brochure. Residents confirmed that they were able to exercise choice about what they did in the home and could come and go as they pleased. Residents can bring personal possessions into the home, and many had done so, however, items of furniture and electrical equipment must meet the relevant safety standards. The kitchen area is well organised, clean, and hygienic; an inspection had been carried out by the environmental health officer and no requirements or recommendations were made. Records relating to food show that each resident is getting a balanced, healthy diet, and individual likes and dislikes are recorded by the kitchen staff. Lunch on the day of inspection was toad in the hole with fresh vegetables and roast potatoes, followed by tinned fruit and ice cream, an alternative was provided for those who wanted a different meal or who needed a special diet. Meals are served in the two dining areas, which provides a pleasant, homely and relaxed atmosphere. Residents said that the food was very good and that they were happy with the quality and quantity of the food provided. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 standard(s) 16, 18 The home’s systems for dealing with complaints are satisfactory so that anyone who felt the need to make a complaint could be sure it would be dealt with properly. The arrangements for ensuring the protection of service users from neglect or harm are satisfactory, and residents are protected from abuse or mistreatment. EVIDENCE: The home has a complaints procedure to tell people how to make a complaint about the service; the procedures are satisfactory. No complaints have been made since the last inspection and residents said that they would feel able to tell staff or the manager if they had a complaint or suggestion. The home has an adult protection policy to guide staff in dealing with allegations of abuse or mistreatment, and there is also a whistle blowing policy aimed at encouraging staff to voice any concerns. Staff spoken to were clear about the need to make sure residents are protected from mistreatment and said that they would feel able to talk to the manager if they had any concerns. Records relating to the money kept on behalf of 2 residents were seen and were in order. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The home is suitable for the needs of those living there, and sufficient equipment is provided so that service users’ independence is maximised. The home is clean and hygienic and there are no unpleasant odours. EVIDENCE: The home is next to the main shopping centre of Whittlesey, which has a range of local facilities including shops and pubs. The building has been adapted and fitted with aids to meet the needs of older people, and it is well-maintained and has a homely and pleasant atmosphere. An ongoing programme of maintenance is in place, and a block paved patio area has recently been created. Access to the building is via ramps, the second floor is accessed by stairs or a shaft lift. CCTV cameras are present in the car park to improve security. Residents have access to a range of communal space including two dining rooms and two lounges, one of which has a conservatory; a designated smoking area is also provided. The communal rooms are well-lit, and furnishings and fittings provided, are clean, domestic in scale and design, and The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 14 appeared both comfortable and suitable for their purpose. Outdoor space is accessible to people with restricted mobility. The home has 8 toilets and 4 bathrooms, one having a shower facility. Two bedrooms have en-suite bathrooms with toilets; all rooms have washbasins. The building has been adapted to suit the needs of older people, and appropriate aids and adaptations are been provided throughout the home including bath hoists and grab rails, both in bathrooms and toilets, and around the building. All rooms have a call bell for the occupants to summon help. Bedrooms are well maintained, tidy and clean, and furniture appears to be comfortable and appropriate to the needs of older people. Residents are able to bring personal items and furniture into the home, though they would need to meet fire and electrical safety standards. Pre-set valves have been fitted to baths ensure that the hot water is delivered at a safe temperature. All rooms are centrally heated and residents are able to control the heating in their bedrooms, with support if needed. The home is clean, hygienic and free from offensive odours. Laundry facilities are sited in a separate out-house, therefore soiled articles, clothing and infected linen do not need to be carried through food preparation areas or places where people eat. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Sufficient staff were on duty to ensure that service users’ needs were properly met. Staff were clear about their roles and were competent and properly trained and experienced, so that they could meet residents’ needs. The home’s recruitment procedures meant that appropriate checks were made on potential staff to ensure that unsuitable people were not employed. EVIDENCE: Three care staff were on duty, along with the manager, deputy manager, and kitchen staff. Staff were well presented and were courteous, welcoming and helpful. Care and support at night is provided by two waking staff. The home has a high level of commitment to training in general and the National Vocational Qualification (NVQ) in particular, and 2 members of staff are doing the NVQ assessors award. The people providing the training for the home were meeting with the staff concerned at the time of the inspection; they were complementary about the support they receive, and about the management of the home generally. Staff files include two written references, and Criminal Record Bureau (CRB) checks had been carried out, as had verification of staff members’ identity, and other required checks. The home has a training programme, which includes the statutory training needed to ensure everyone’s safety, such as moving and handling, fire safety and first aid. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36, 38 The home is being managed properly and there is leadership, guidance, and direction for staff to ensure residents receive consistent quality care. Measures were generally in place to ensure that the health, safety and welfare of the people using the service were being protected EVIDENCE: The registered manager has been in post since August 2001 but has worked in the home in other capacities for many years. She has successfully gained NVQ level 3 and is about to complete the Registered Managers Award (RMA) at level 4. The manager is assisted by a deputy manager, who has also gained NVQ level 3 and is working towards gaining the RMA. Staff and residents said that they thought the home was well-run and said that if the need arose, they would not hesitate to approach the manager or her deputy, with any concerns. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 17 Residents are encouraged to manage their own money, however, many have arranged for their personal allowances to be looked after by a relative or other representative. Staff do not act as appointee for the payment of any residents’ benefits; records relating to cash being held on behalf of service users were in order. Staff spoken to during the inspection confirmed that they had been provided with the training necessary for them to carry out their duties safely, including training in moving and handling, fire safety, and first aid. Records relating to health and safety training are displayed in the foyer, and show that updating of training is taking place when it is due. The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 3 x 3 The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 19 NO 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 Regulation None 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 None Good Practice Recommendations The Hermitage I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 20 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB5 0JA 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 I53 I03 15194 THE HERMITAGE V236344 050705 STAGE 4.doc Version 1.40 Page 21 - 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!