Inspection on 05/06/07 for Holbrook Hall

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Holbrook Hall 08/11/05

Holbrook Hall 10/05/05

Holbrook Hall 01/11/04

Holbrook Hall 04/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Holbrook Hall Makeney Road Holbrook Belper Derbyshire DE56 0TF Lead Inspector Tony Barker Key Unannounced Inspection 09:05 5th June 2007 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 Holbrook Hall DS0000020017.V329288.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 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. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holbrook Hall Address Makeney Road Holbrook Belper Derbyshire DE56 0TF (01332) 880698 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) Holbrookhall@aol.com Fairway Homes (Derby) Limited Mrs Barbara Mee Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Holbrook Hall is a large detached stone building set in its own extensive landscaped gardens. Holbrook Hall is situated in a rural setting with a small village, approximately a mile away, which offers basic shopping facilities. 25 single rooms are provided, mainly with en-suite facility accommodation, for older people. There is a shaft lift and stair lift between floors. The fees for the Home are £360 to £440 per week. A copy of the last inspection report from the Commission for Social Care Inspection (CSCI) is made available to residents and visitors. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. Seven residents, the Registered Manager, the Registered Provider, two senior care assistants and one care assistant were spoken to, records were inspected and there was a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to residents and four were returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The Home had purchased new dining room chairs, perching stools, games and activities and special cutlery following a review, by an occupational therapist, of care at the Home. There was evidence of the Home maintaining a high standard of care to residents. No requirements or recommendations were made at the last inspection. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 6 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 summary of this inspection report can be made available in other formats on request. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 7 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 Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents who use this service have good information about the Home in order to make an informed decision about whether the service is right for them. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: Several documents were displayed in the entrance hall for the attention of residents and visitors. These included the Home’s Statement of Purpose, Service Users’ Guide, complaints procedure, the last inspection report, the extra charges made by the Home and an information leaflet on the CSCI. The Home is commended for the range of information about the Home that is readily available to residents. The most recently admitted resident was case tracked and this person’s file was examined. This resident was self-funding and there was a full, recorded Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 9 pre-admission assessment of need undertaken by the Home. This was based on information taken from the person and their relatives during one day prior to admission. The most recently admitted resident had spent this one day in the Home to give them, and the Home, opportunity to decide on the appropriateness of admission. This introductory day took place prior to each admission and the Manager added that emergency admissions do not take place. The ‘Personal Details of Day Visitor’ sheet was examined in this case tracked resident’s file and found to give helpful details. All documents were dated and signed. The Home was not providing intermediate care. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents had an individual plan of care which demonstrated that their health, personal and social care need were being well met. They were being treated with respect and their right to privacy was upheld. EVIDENCE: The recorded care plans on each case tracked resident’s file were examined and found to provide detailed and person-centred accounts of their needs and the actions staff should take to meet these needs. Care plan documents included photographs of residents, personal and family information, personal history, care/action plans and risk assessments. A record of favourite foods, colours and music, as well as ‘real dislikes’ showed the Home was following a ‘person centred approach’. Care plans were being reviewed monthly, in a comprehensive way and staff and residents confirmed their full involvement in these reviews. The two staff spoken to said, in one instance, relatives who were living abroad were faxed a copy of the resident’s care plan. The Home is commended for its diligence in ensuring that residents’ unique and individual needs are at the centre of care provided. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 11 Risk assessments were being recorded in respect of Moving & Handling, falls, tissue viability and nutrition. Tissue Viability, nutrition and weight were being reviewed and recorded each month, with dates and signatures. Records showed that a range of health professionals were involved with the health care of residents and good accounts of these visits were being recorded. Medication was being securely stored. Case tracked residents’ Medication Administration Record (MAR) sheets were examined. These were generally satisfactory although there were several examples of handwritten entries having only one or no signature beside them. ‘As and when required’ (prn) paracetamol was being recorded by signature, though there was no separate record of the reasons for the administration. All those staff who administer medicines had had training in the safe use of medicines, staff informed the Inspector. A medication refrigerator was in place. One case tracked resident had signed a ‘Self Administration of Medicines’ form. Residents, who completed the pre-inspection survey forms, confirmed that staff listen to them and act on what they say. One case tracked resident stated that, “I couldn’t ask for better care” and another said, “I am treated as an individual”. Both were well turned out and they confirmed that there was a very good and quick laundry system. The staff spoken to gave examples of residents’ need for privacy, dignity and choice being met. Staff were observed taking a personal interest in residents and treating them with care and dignity. Some residents’ files contained a signed request for “Cessation of hourly night inspections (by care staff)”. This indicated that their privacy and dignity were being considered. The Manager confirmed that no resident took a bath on their own. She agreed to ask residents whether they would wish to spend some time alone in the bath, in private and, if so, to record a risk assessment. The Home is commended on the degree of respect given to residents in their daily lives. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities at the Home were diverse and benefited residents. The Home encouraged family contact and provided residents with meals which were varied and which they enjoyed. EVIDENCE: There was evidence from the Manager, Provider and residents that the Home respects residents’ personal routines whenever possible. Examples included where and when meals are served, whether to follow through with hourly night calls on residents, and respecting residents’ wishes about going into their bedrooms at certain times of the day. The Provider said, “We organise around residents’ personal routines”. There was a good range of activities organised, both within the Home and outside. Both the case tracked residents who were spoken to said they felt adequately stimulated – either by their preferred personal daily routine or by activities provided by the Home. One case tracked resident with poor eyesight spoke of staff calling out the numbers from the game being played during the morning of this inspection – using large playing cards – so more residents could take part. The Home had purchased new games and activities following a recent review, by an occupational therapist, of care at the Home. The residents surveyed by post felt that there were always, Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 13 or usually, activities they could take part in. One said, “We have outings every two weeks...very enjoyable and popular...I get wheelchair assistance...the carers are very helpful”. Another resident stated that “members of my church are always welcome (at the Home) as are other denominations”. Three residents attend the local C of E church each Sunday. Activities arranged by the Home also include weekly reminiscence sessions which include quizzes, videos of old Derby and Holbrook, and reminiscence bingo. Activities were referred to in the Home’s six-monthly newsletter. The Home is commended on its attention to residents’ need for stimulation and social, recreational and religious activities. The Home’s Visitors Book confirmed frequent visits to the Home by relatives and friends. The two case tracked residents who were spoken to both confirmed they received regular visitors who took them out or could stay for as long as they liked. Details of the Age Concern Advocacy Service were displayed in the Home. The Manager said that currently no residents needed an independent advocate although this Advocacy Service had been used in the past. The Manager described how one resident was helped to choose a bed that they specifically wanted and how the Home put in additional power points and shelving in this person’s bedroom for electrical equipment used by the resident for their recreation. Lunch was observed in the dining room: tables were very attractively laid out and included fresh flowers. There was a positive atmosphere in the room. The meal looked appetising and residents spoke highly of the quality of food provided. The day’s menu was displayed in the entrance hall. The Home’s four-weekly rolling menus were examined and these showed that residents were being provided with a varied and balanced diet. When residents choose an alternative meal this is recorded in a book held in the kitchen. A visit was made to the kitchen and foodstocks were at a good level, with fresh fruit and vegetables. The cook explained that all residents are given the option of having sherry with their evening meal and red or white wine with Sunday lunch. She added that most of the cakes are made in the kitchen. Residents who responded to the postal survey stated that they liked the meals at the Home. The Manager spoke of one resident who requests breakfast at 6am each day in their bedroom and who has a very individual diet at all mealtimes. One of the case tracked residents spoken to stated that, “The food is excellent and the mealtime service”. The Provider stated that, “We accommodate all food preferences” and added that, “The cook loves to have residents ask for something special”. She said that she sets no limits to the catering budget. Special cutlery had been purchased following the occupational therapist’s review. The Home is commended on its catering service. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Robust procedures for handling complaints and abuse were in place ensuring residents were fully protected. EVIDENCE: The Home had a well worded complaints procedure that was displayed in the entrance hall. The pre-inspection questionnaire indicated that seven complaints had been received by the Home within the previous 12 months. These were examined from the Complaints Book and all were relatively minor concerns raised by residents. They provided further evidence of the Home listening to residents and taking appropriate action. There had been no formal complaints made – the Home had a form for completion in the event that any were made. Residents who responded to the postal survey knew who to speak to if they were not happy. One case tracked resident told the Inspector that their key worker and the Manager are both approachable. All staff had been provided with external ‘safeguarding adults’ training by Derby County Council, the Manager said. The staff spoken to confirmed they had been provided with this training and they showed an awareness of the Home’s whistle blowing policy. The Manager and the Provider undertook a refresher course in Adult Protection last year. A copy of Derbyshire’s Safeguarding Adults’ procedures was being kept within the Home. The documents displayed in the entrance hall included information leaflets on Adult Protection and leaflets on ‘Looking after yourself during hot weather’. There Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 15 was also a note to visitors to “make sure relatives have got sun hats and cream”. The Provider spoke about risk assessments being used, in the past, to record any risk of residents wandering from the Home. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were living in an attractive and comfortable environment that was clean and hygienic. EVIDENCE: The Home was attractively furnished and decorated and was homely in appearance. Corridors were fitted with handrails for the safety of residents with poor mobility. New dining room chairs, and perching stools, had been purchased following the occupational therapist’s review. The staff toilet door had an internal bolt and no emergency call system call point. It was brought to the Manager’s attention that there was a small chance of a resident using this toilet and not being able to summon help. Also, there were stairs leading to a second floor attic that could create potential risk to residents. Options to reduce or remove these two risks were discussed. Two case tracked residents’ bedrooms were visited. These were both comfortably furnished and were well personalised. One of these residents said, of the Home’s location, “It is ideally Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 17 situated here”. The Home had a most attractive and well maintained garden. Three residents were seen sitting outside on a sunny afternoon during this inspection. Additionally, there was a small, enclosed courtyard for residents’ use. The premises were clean and hygienic. Residents and relatives who responded to the postal survey confirmed that the Home was always fresh and clean. One said, “The cleaners will do anything to help you if possible”. The staff spoken to described good infection control practices and said they had received infection control training. The Home’s washing machine had a sluicing programme. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had a group of well trained staff to ensure that residents were safe and their needs were met. EVIDENCE: The staffing rotas were examined and these indicated that staffing levels were adequate. Residents who responded to the postal survey said that staff are available when they are needed. One commented, “Carers work very hard”. One case tracked residents said, “You won’t find better carers, here”. Another said, in relation to staffing levels, “I’m never needy”. The Manager’s pre-inspection questionnaire showed that 76 of care staff had achieved a National Vocational Qualification (NVQ) in Care at level 2. This exceeded the 50 level required by the National Minimum Standards. All but one of these staff had achieved an NVQ in Care at level 3. Two further staff were working towards NVQ level 3. The Home’s commitment to providing staff with NVQ level 3 training is commendable. The file of a recently appointed member of staff was examined. Matters relating to her recruitment were satisfactory. However... • although the Home’s job application form had a section headed ‘Declaration of Convictions’ it did not explicitly ask the applicant whether they have been Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 19 convicted, or cautioned, of any criminal offences. No mention was made of ‘spent’ convictions, • the job application form did not provide a place for the applicant to record reasons for leaving a previous job, • the employment record did not require the applicant to provide dates of previous employment, in months, in order to highlight any gaps in employment. Criminal Records Bureau (CRB) checks were in place, for all staff. The Manager stated that all staff had been provided with mandatory training. There was no ’at a glance’ training matrix available for quick confirmation of this. The pre-inspection questionnaire indicated that staff were being provided with a training courses of relevance to their needs. These included courses on dementia. The staff spoken to confirmed they had attended a number of training courses over the previous 12 months. There was evidence of induction and foundation training meeting the specifications laid down by ‘Skills for Care’. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Home was well managed so that residents were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager had 34 years experience of working with older people, six of these as Manager at Holbrook Hall. Both the Manager and Provider had attained the Registered Managers Award and had an NVQ in Care at level 4. The Provider’s achievement of these qualifications enables her to provide informed and professional support to the Manager. This is commendable. The staff spoken to said, of the Home, “It is a very friendly place...like family”. They confirmed that both the Manager and Provider are approachable. One case tracked resident, who was due to move into another care home nearer Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 21 relatives, stated, “I am leaving here very sadly”. The Manager described good management practices including delegation of specific tasks, by the senior care team, to care assistants. Records of the monthly, unannounced audit visits to the Home, undertaken by the Provider, were examined and found to be satisfactory. There was also a good range of other quality monitoring systems. The Home had no recorded annual development plan though there was good evidence of thoughtful planning. The Home’s Quality Assurance file contained... • satisfaction questionnaires completed by relatives and staff: collated responses were positive, • comments and suggestions from residents, • minutes of six-monthly Residents Meetings - those from the last one in February 2007 were examined, • letters from visitors to the Home, such as the hairdresser and relatives, who had been asked to report their own lunchtime experiences at the Home, • notes from occasional ‘Quality Circle’ meetings – groups of residents who were asked for their opinions about a range of matters, • a list of matters arising from recent Commission for Social Care Inspection’s (CSCI) inspections reports of six local care homes. Documents available in the entrance hall included... • an informative six-monthly newsletter that included news of staff and residents, and details of complaints, comments and suggestions received, • Comments and Suggestions Cards and Box, • a copy of the last inspection report from the CSCI. Both the Manager and the Provider showed a keenness to make improvements where these were indicated by the Inspector. The Home’s approach to quality assurance is commendable. The three case tracked residents had control of their own money. Those residents’ personal monies being held by the Home were secure. There was a robust system in place for recording all transactions, including double signatures against each. One resident’s monies were cross-referenced against the current balance figure and were found to be correct. Cleaning materials were being safely stored in a locked cupboard, together with Product Information Sheets. The pre-inspection questionnaire showed that equipment was being checked and maintained appropriately. Fire drills were being carried out three to four times a year. Good food hygiene practices were being followed. Accident records, and a monthly collation of these, were examined. Annual Health & Safety checks of the premises were being carried out. The Manager said that all staff had had Health & Safety training. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 22 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 4 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 X 3 X X 3 Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. 2. 3. 4. 5. 6. 7. Refer to Standard OP9 OP9 OP10 OP19 OP29 OP30 OP33 Good Practice Recommendations All hand-written entries, on medicine records, should be signed, countersigned and dated, in order to maintain a clear audit trail. Staff should record details of the circumstances why ‘prn’ (as and when required) medication is administered. Residents should be asked whether they wish to spend some time alone in the bath and, if so, a risk assessment should be recorded. Potential risks to residents, of using the staff toilet and the stairs to the attic, should be addressed. The wording of the Home’s job application form and employment record should be reviewed so as to provide further safeguards when appointing staff. An ’at a glance’ staff training matrix should developed. The Home should create an annual development plan. Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Holbrook Hall DS0000020017.V329288.R01.S.doc Version 5.2 Page 25 - 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!