Inspection on 07/08/06 for The Hermitage

This inspection was carried out on 7th August 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 found no outstanding requirements from the previous inspection report, but made 4 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 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 7th August 2006 09:30 The Hermitage DS0000025850.V306938.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.V306938.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.V306938.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 Borders and Partnership NHS Trust Mrs Kim Baldacchino Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Hermitage DS0000025850.V306938.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. Date of last inspection Brief Description of the Service: The Hermitage is a ten place residential home for people with learning disabilities. 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 fee charged at the home is between £57,752.00 per annum or £1,108.00 per week. The Hermitage DS0000025850.V306938.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 9.30am and 2.30pm on a Monday morning/afternoon. The registered manager, Mrs Baldacchino, was not present in the morning; the deputy manager ably supported the inspection process until Mrs Baldacchino came to the home in the afternoon. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with two service users, the deputy manager and Mrs Baldacchino. Records examined included service users person centred plans, care plans, risk assessments, complaints, adult protection, staffing records, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed with Mrs Baldacchino. What the service does well: The home provides prospective service users and their representatives with the information they need to make an informed decision about whether or not to use the service. All service users have a person centred plan that includes detailed information on their needs and personal goals. Two service user files sampled at random indicated that the service users had had their needs assessed by a care manager from their placing authority. The arrangements for meeting the health care needs of the service users are good and service users receive personal support in the way they prefer. The home has the support of a pharmacist for advice and a report from a visit on the 18th May 2006 indicated that medication is stored and recorded appropriately. Service user meetings take place on a regular basis; minutes of these meetings indicate that service users are able to participate in the running of the home. One service user said that she is planning to go to Spain on holiday this September but is still considering what part of Spain to go. Mrs Baldacchino said that all service users would go on holiday either to Spain or Tunisia this year. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 6 The homes menus are based on the likes and dislikes of the service users. The home has sought the advice of the Surrey and Borders NHS Trusts dietician for some service users. Service users bedrooms have been decorated to their own personal choices. Service users spoken to on the day of the inspection said that they were happy with their rooms and the new garden furniture. A relative’s questionnaire returned the Commission as feedback indicated that they were very happy with the level of care provided and that their loved one was very well looked after What has improved since the last inspection? What they could do better: There were three requirements and four recommendations set at the last inspection. All three requirements and two of the recommendations were met. As a result of this inspection four new requirements and five new recommendations have been set. There are now four requirements and seven recommendations. The overall impression when visiting the home is that it is well organised and well managed however there were a number of weaknesses identified during the inspection, the most significant being that gas safety checks and portable appliance testing had not been carried out at the home. The health and safety of the service users could be compromised if the home does not ensure that these tests are carried out. Mrs Baldacchino provided evidence that most of the staff team had completed adult protection training however unless all staff is trained on adult protection The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 7 there is the risk that service users will not be protected in a consistent manner from abuse. Some service users risk assessments need to be reviewed and updated. The inspector would like to thank the service users, members of staff on shift and the deputy manager and Mrs Baldacchino for their support during the course 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.V306938.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.V306938.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 at least once during a 12 month period. 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 all the available evidence including a site visit to this service. No new service users have moved to the home since the last inspection. The home provides prospective service users and their representatives with the information they need to make an informed decision about whether or not to use the service. EVIDENCE: The homes Statement of Purpose has been reviewed and updated as required at the last inspection. The registered manager, Mrs Baldacchino, recently made a successful application to the Commission to reduce the number of service users supported at the home. The home is now registered to support ten (10) people with learning disabilities. There are (10) service users living at the home at present. Unfortunately one service user passed away in April this, no new service users have moved into the home since the last inspection. The Surrey and Borders NHS Trust has an Admission Procedure, that states that service users 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 home, along with any other information about the service users needs. The family of the service user is also involved, if it is appropriate. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 10 The fee charged at the home is between £57,752.00 per annum or £1,108.00 per week. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 all the available evidence including a site visit to this service. All service users have a person centred plan that includes detailed information on their needs and personal goals. In general individual risk assessments and risk management strategies in place so that service users can participate in activities in the home and in the community in a safe manner. Service users are able to make decisions about their lives through the Person Centred Planning process and attending and participating in service user meetings. EVIDENCE: Two service users personal files were sampled at random. Both service users files included recent needs assessments completed by a care manager from their placing authority. Both service users had a Person Centred Plan that included headings such as what matters to me, things I enjoy, places I go, things to do in order to keep me healthy, my dreams and aspirations, a relationship circle and how I communicate. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 12 Service user meetings take place on a regular basis; the minutes of these meetings indicate that service users are able to participate in the running of the home. Risk assessments were in place, reviewed and updated in one service users file however risk assessments in the others service users file was due to be reviewed and updated in March 2006. Mrs Baldacchino provided evidence that the home and the pschologist are continuing to set up behavioural guidelines for staff to support this particular service user and this has been very benificial to the service user. It is recommended that the registered manager check all of the other service users risk assessments to ensure that they are reviewed and updated. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 all the available evidence including a site visit to this service. In general service users benefit from a choice of recreational activities both in and outside of the home. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. EVIDENCE: The home has an activities coordinator. A weekly activity chart indicated that service users go to the cinema in Streatham, bowling in Purley Way however the deputy manager stated that service users have not been able to attend the cinema, Mrs Baldacchino stated that this was because of the logistics of getting some service users to Geoffrey Harris House and others to the cinema at the same time. Mrs Baldacchino stated that bowling sessions have now been booked for the service users. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 14 The deputy manager stated that service users frequent the local cafes, hairdressers, barbers, shops and cafes, a Saturday Club, Monday Club and an Aroma Therapist visits the home on Thursday afternoons. Not all activities that service users attend are recorded on the weekly activity chart. It is recommended that the registered manager reviews and updates the weekly activity chart to include the activities that the service users can actually attend. 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 and service users recently went on day trips to Brighton and Chessington World of Adventure. One service user said that she is planning to go to Spain on holiday this September but is still considering what part of Spain to go. Mrs Baldacchino said that all service users would go on holiday either to Spain or Tunisia this year. The home has an open visitors policy and staff just ask that people phone ahead of any visit to check that the service user is at home. There was evidence that service users relatives are able to visit them at the home. The homes menus are employed on a four-week rota and are based on the likes and dislikes of the service users. The Surrey and Borders NHS Trust dietician checks menus for nutritional balance. The home has sought the advice of the dietician for some service users and appropriate guidelines are in place. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 the service users are good and service users receive personal support in the way they prefer. Service users now have a health action plan that includes an in depth assessment of their needs and a record of health care appointments. The homes policies and procedures for handling medicines ensure that the service users are so far as reasonably practicable protected from harm and/or abuse. EVIDENCE: All service users are registered with a General Practitioner. There was evidence in the service users files sampled that they are supported to attend health care appointments. Service users Person Centred Plans indicate their level of support needs and how the service user prefers personal care to be carried out. The deputy manager provided evidence of guidelines for staff to support some service users with challenging behaviour. There was evidence that a number of The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 16 staff had recently attended training on intervention strategies for challenging behaviour. 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. Service users now have a health action plan that includes an in depth assessment of their needs and a record of health care appointments. Mrs Baldacchino stated that these had only recently been introduced to the home and these are in various stages of completion. The home has the support of a pharmacist for advice and a report from a visit on the 18th May 2006 indicated that medication is stored and recorded appropriately. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 the service users are so far as reasonable practicable protected from abuse however unless all staff are trained on adult protection there is the risk that service users will not be protected in a consistent manner from abuse. EVIDENCE: The home has a complaints procedure in widget and picture form for the benefit of some service users. Mrs Baldacchino produced evidence that nine members of staff have attended adult protection in the last two years however four members of staff has yet to attend adult protection training. Mrs Baldacchino stated that these staff are on a waiting list for adult protection training but she was not sure if or when these staff had attended the training. The registered manager must ensure that all members of staff attend adult protection training. A relative’s questionnaire returned the Commission as feedback indicated one of the service users relatives was not aware of the homes complaints procedure. It is recommended that the registered manager forward a copy of the homes complaints procedure to all the service users relatives. Another relative’s questionnaire returned the Commission as feedback indicated that they were very happy with the level of care provided and that their loved one was very well looked after. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 18 The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 overall impression when visiting this home is that it is generally well decorated, homely, comfortable, clean and hygienic. EVIDENCE: 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. A patio has been laid in the garden and new furniture has been purchased. Three service users spoken to on the day of the inspection said that they liked to sit in the garden when it was sunny; one service user said that she doesn’t like the sun but sits under the tree in the shade. Service users bedrooms have been decorated to their own personal choices. Service users spoken to on the day of the inspection said that they were happy with their rooms and the new garden furniture. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 20 Skirting boards on the ground floor have been scratched by wheelchair use; Mrs Baldacchino said that she would ask the domestic staff to touch this up with a bit of paint. During the last inspection it was noted that some staffing information was stored in the dining room area. All staffing information is now stored in the homes office. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable service users are not placed at risk of harm or abuse. The registered manager needs to ensure that the staff team receives regular supervision so that the service users benefit from having a consistent approach to their needs. EVIDENCE: It was noted at the last inspection on the 29th of November 2005 that Mrs Baldacchino had completed a training programme for all staff at the home. Staff had attended training on Fire Safety, Manual Handling and Confidentiality. The manager was planning further staff training on Health and Safety, Vulnerable Adults and Food Hygiene. Six staff, the manager and the deputy manager had been trained on First aid and staff had training on Medication. Eleven members of staff had completed NVQ level 2 and two members of staff had completed NVQ level 3. Mrs Baldacchino was assessing another member of staff completing NVQ level 3. The home has the support of a Domestic and she is also completing an NVQ. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 22 Mrs Baldacchino produced a supervision matrix indicating dates when staff received supervision. Mrs Baldacchino stated that due to the Surrey and Borders NHS Trusts implementation pf the Knowledge for Skills Framework she has not supervised staff at the required frequency. Mrs Baldacchino stated that staff has completed appraisal questionnaires and attended regular team meetings however she is aware that regular supervision must be carried out. The registered manager must ensure that all members of staff receive supervision at least six times a year. As required at the last inspection all the information required in Schedule 2 National Minimum Standards for all members of staff employed in the home is kept on file. A requirement was set at the last inspection that the registered manager writes to the Commission for Social Care Inspection when she receives the other five members of staffs Criminal Records Bureau Checks and arranges a date for these to be inspected. Mrs Baldacchino contacted the Commission regarding the Criminal Records Bureau Checks. Full enhanced Criminal Records Bureau Checks were seen for three of above members of staff. One Criminal Records Bureau Check was with the service manager. The remaining member of staff, an existing member of staff when Criminal Records Bureau Checks were first required and had worked at the home for a number of years, was having problems obtaining a Criminal Records Bureau Check. Mrs Baldacchino stated that this was due to lack of documentation accepted by the Criminal Records Bureau as proof of identification. Mrs Baldacchino stated that she is working with the member of staff and the Criminal Records Bureau to clarify the issue. Three new members of staff are due to start work in the home in September; Mrs Baldacchino stated that none of these staff would start work until full Criminal Records Bureau Checks have been obtained. It is recommended that the registered manager contact the Commission when all Criminal Records Bureau Checks are available in the home for inspection. The Hermitage DS0000025850.V306938.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 at least once during a 12 month period. 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 overall impression when visiting the home is that it is well organised and well managed however the health and safety of the service users could be compromised if the home does not ensure that portable appliance testing is carried out and a corgi approved engineer checks the homes gas system. 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: Mrs Baldacchino has managed The Hermitage for two years; she has managed other care homes within the Surrey and Borders NHS Trust over the last ten years. She has completed the Registered Managers Award and NVQ level 4 in Care. She is also a Registered Nurse and she also holds NVQ units D32 and D33 enabling her to assess staff completing NVQ’s. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 24 There was evidence that a service user and service users relatives survey had been carried out in June 2005. Mrs Baldacchino stated that she had recently posted copies of the Commission For Social Care Inspections questionnaires to relatives and was in the process of to completing/sending the homes survey questionnaires to service users and their relatives again. Regulations 26 visits are carried out by the organisation in order to inspect the premises of the care home, its record of events and records of any complaints, form an opinion of the standard of care provided in the care home and prepare a written report on the conduct of the care home. Mrs Baldacchino has regularly sent monthly copies of the Care Homes Regulations 26 visit reports to the Commission. Although a legionella test had been requested by the home and receipts have been signed by staff that the work had been carried out by the Surrey and Borders works department, it is not clear when the legionella test was carried out. It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. Mrs Baldacchino could not provide evidence that Portable Appliance Testing had been carried out; she contacted the works department and was informed that evidence of the test would be the reciepts passed to staff by the works department following completion of the test. On examination of plug sockets it was evident that a Portable Appliance Test had been carried out in June 2005 and was due again in June 2006. There was no evidence that a portable appliance test had been carried out this year. The registered manager must ensure that portable appliance testing is carried out at the home and a copy of the portable appliance testing certificate is sent to the Commission For Social Care Inspection upon receipt. A Landlords Gas Safety Certificate was seen for the 28/04/05. No checks on the homes gas system had been carried out since that time. Mrs Baldacchino contacted the works department and was informed that the works department would now carry out annual gas safety checks and a date needs to be arranged to check the Hermitage. The registered manager must ensure that a corgi approved engineer checks the home gas system and a copy of the Landlords Gas Safety Certificate is sent to the Commission For Social Care Inspection upon receipt. Ten members of staff attended fire safety training on the 12/05/06 and all members of staff have read and signed to say that they understood instructions contained in the premises fire manual. The Surrey and Borders NHS Trust has carried out quarterly fire alarm tests and the trusts fire officer reviewed the homes fire safety risk assessment on the 18/05/06. Mrs Baldacchino also carries out regular three monthly fire The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 25 safety audits. There is evidence that the fire alarm system is checked on a regular weekly basis. However the fire alarm system had not been checked for twelve days. The deputy manager stated that she generally checks the system on a Wednesday however she was off that day so the check was not carried out. The deputy manager ensured that the fire alarm system was checked on the day of the inspection. It is recommended that all members of staff take responsibility for checking the fire alarm system. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 26 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 2 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 3 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 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 27 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. 2. Standard YA23 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 receive supervision at least six times a year. The registered manager must ensure that Portable Appliance Testing is carried out at the home and a copy of the Portable Appliance Testing Certificate is sent to the Commission For Social Care Inspection upon receipt. The registered manager must ensure that a corgi approved engineer checks the home gas system and a copy of the Landlords Gas Safety Certificate is sent to the Commission For Social Care Inspection upon receipt. Timescale for action 31/10/06 07/08/06 YA36 3. YA42 13 (4) a 07/08/06 4. YA42 13 (4) a 07/08/06 The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 28 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. 5. 6. 7. Refer to Standard YA9 YA12 YA22 YA34 YA20 YA42 YA42 Good Practice Recommendations It is recommended that the registered manager check all of the other service users risk assessments to ensure that they are reviewed and updated. It is recommended that the registered manager reviews and updates the weekly activity chart to include the activities that the service users can actually attend. It is recommended that the registered manager forward a copy of the homes complaints procedure to all the service users relatives. 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 registered manager discuss the homes medication administration procedure with the whole staff team. It is recommended that staff date the receipts when the works department carry out testing or other maintenance work at the home. It is recommended that all members of staff take responsibility for checking the fire alarm system. The Hermitage DS0000025850.V306938.R01.S.doc Version 5.2 Page 29 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. 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