CARE HOMES FOR OLDER PEOPLE
Holcombe House Butterton Lane Moretonhampstead Newton Abbot Devon TQ13 8PW Lead Inspector
Stella Lindsay Key Unannounced Inspection 17th July 2007 10:15 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 Holcombe House DS0000003722.V341419.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. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Holcombe House Address Butterton Lane Moretonhampstead Newton Abbot Devon TQ13 8PW 01647 440241 01647 441146 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) Mrs S.E. Owens Mrs S.E. Owens Care Home 21 Category(ies) of Dementia (21), Old age, not falling within any registration, with number other category (21), Physical disability over 65 of places years of age (21) Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th May 2006 Brief Description of the Service: Holcombe House is registered to provide accommodation and care for up to twenty-one people who are over sixty-five and who may have dementia and/or a physical disability. There are 17 bedrooms, four of which are large enough to be occupied by two people. There is a pleasant dining room adjoining the lounge at the back of the house, and another lounge and conservatory at the front. Three outdoor spaces have been prepared for residents to enjoy in safety, while the extensive grounds provide an attractive setting for the home. The home is about half a mile from the centre of Moretonhampstead and has panoramic views over Dartmoor. A written Statement of Purpose and the most recent inspection report are available on request at the home, and a Service Users’ Guide will be sent to prospective on request. The fees are currently £450 and additional charges will be made for professional hairdressing, chiropody, newspapers and toiletries. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days in July 2007. It involved a tour of the premises, and discussion with the home owner, the Deputy Manager, and three other staff on duty, five visiting relatives, and discussion or observation with 15 of the 20 people who were in residence at the time. The inspector shared a meal with residents and spent some time in the lounges as well as visiting some in their private accommodation. Care records and staff files were examined, and the medication system was inspected. The Home Owner had supplied additional information prior to the inspection, and questionnaires had been returned to the CSCI by a random sample of staff, residents’ relatives, and some health and social professionals who are in contact with the service. What the service does well: What has improved since the last inspection?
The recording of assessment of clients’ needs before offering accommodation has improved, in order to ensure that the service is offered appropriately, and that the home can prepare for any special needs. A letter is now sent to the prospective resident or their representative when the decision is made, to assure them that the home is able to meet their needs.
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 6 Each resident now has a care plan, and residents and relatives are being invited to reviews. The dining room and back lounge had been redecorated in a calm shade of green, with a new carpet and most attractive curtains. The conservatory had also been recently redecorated, giving another alternative place to sit. Two pleasant areas of the garden had been made accessible for residents, though they need to be accompanied, and a balcony can be accessed from the dining room. Domestic chemicals were being safely stored, to avoid potential harm. Staff had been provided with hand washing fluid to carry with them. Residents had been assessed with regard to their ability to benefit from a lock on the door to their private accommodation. One person had been provided with a keypad type lock, for their privacy and dignity. The staff recruitment practice had improved, and checks had been made on candidates, to avoid potential harm to residents. What they could do better:
Each resident has a care plan which has been up-dated and regularly reviewed. They would benefit from a summary of the care that is needed along with the residents’ preferred times, which in the case of people with diabetes must include nutritional needs. It would be good practice to write a life history or personal profile with or for each resident, to help staff develop their understanding of them. It was recommended that professional advice be sought with regard to a resident whose mobility had decreased, to make sure that their safety was being assured in the best way. The recording of medication was generally good, but needed to be improved to include any reason why a tablet is not given, and the dose given when it can be varied, such as pain-killers, for proper accountability and to promote the residents’ health and well being. The water in hot taps of residents’ upstairs bedrooms was running very hot, and there was a danger that hey might be scalded unless thermostatic valves were fitted. Suitable locks should be fitted to communal toilets and bathrooms, because with the bolts that were in place there was a danger that staff might not e able to gain access in an emergency. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 7 Some radiators still needed to be covered so that residents would not be in danger of harm if they were to fall or roll against them. Liquid soap and paper towels should be provided in communal toilets to promote good hygiene. Further improvements to the surface of the area around the house would enable and encourage residents to enjoy the gardens and patios more easily. A quality monitoring system should be adopted, to gain feedback from residents, relatives, staff and others in a systematic way, and to involve them in the ongoing development of the home. 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. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 8 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 Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. Clear information is provided, and the management ensure that they meet with prospective residents and their families in the course of assessing the suitability of the home to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service User Guide had been up-dated in June 2007, and was clearly presented with all the information required by this standard in a very readable form. It also included the home’s statement of Terms and Conditions, their policy on shared rooms, and how to access the CSCI inspection reports. A web site is being prepared. The two most recently admitted residents were already known to the Managers because of attendance at Holcombe Day Care Centre, which is next door, and under the same ownership. Another knew the home before moving in, having visited their own mother and aunt in previous years.
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 10 While gathering information to judge whether the home can suitably meet the person’s needs, the Managers use an assessment form that has been designed to ensure that the wide range of care needs are considered, including communication and social interests, as well as personal and health care needs. Clients and their families are encouraged to visit, to see for themselves what the home is like. One visiting family told the inspector that they had been impressed when first visiting Holcombe House by the great dignity with which residents were being treated. A letter has been prepared to send to prospective residents, or their representatives, following assessment, to assure them that the home will be able to meet their needs. Intermediate care is not offered at Holcombe House. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 11 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 good. Residents are treated with respect, their individuality valued. Good personal and health care practices are maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a care plan which has been up-dated and regularly reviewed. They would benefit from a summary of the care that is needed along with the residents’ preferred times, which in the case of people with diabetes must include nutritional needs. A care plan had been displayed on the inside of wardrobe doors in residents’ bedrooms. This is good practice, for staff to refer to easily as well as for residents and their relatives to know what has been agreed, but should be kept up to date. Relatives were being invited to reviews of care plans. One family who were visiting told the inspector that they had been involved in a Care Plan review the week before this inspection. They were ‘extremely happy’ with their mother’s care. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 12 Senior staff had been trained to provide diabetes care. Good practice was in place to manage continence and prevent pressure sores. In the case where bed rails were in use, it was on professional advice. An Occupational Therapy assessment should be sought on behalf of a resident whose mobility and balance had deteriorated. They had been given a bean-bag to sit in, for their safety and comfort. The Managers were aware that this is a form of restraint, for the person’s safety. Holcombe House has a policy and procedure for the safe administration of medication. It is made clear in the Statement of Purpose that residents who wish to self-medicate are not admitted. Medications are stored securely, and at all times a Senior on duty is designated to hold the key and take responsibility. Records were seen to demonstrate that the senior staff had received training in the administration of medicines. An inspection of the medication records and stored medication demonstrated that the arrangements in place for the administration of the residents’ medication are satisfactory, with two exceptions. There should be a way of recording the reason, when any tablet is not given. Variable dosage (PRN) tablets (such as pain killers) and non-prescription remedies should be recorded alongside the medication records, along with the reason for giving them and the dose given, for proper accountability. Some residents had family photographs and albums, and staff had good knowledge of individual life histories and interests. It would be good practice to write a life history or personal profile with or for each resident, to help staff develop their understanding of them. Good principles of care are insisted upon at Holcombe House. Privacy and dignity are preserved and individuality is valued. Visiting relatives had been impressed by staff who had said that they regard it as a privilege to work with the residents. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 13 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. A good variety of social activities are offered, following consideration of individual interests, and discussion in Residents’ Meetings. Good meals are provided, using fresh ingredients, and improvements in the choice offered are being arranged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are helped to maintain some control over their lives, and are given opportunities to join in social activities. A white board outside the front door showed the activities on offer – but the residents indoors could not see it. Activities are offered each afternoon. During this inspection a craft teacher kept several residents engaged in artwork through the afternoon, and they produced attractive decorated butterflies, with their varying skills, and evidently were enjoying this activity. Residents were also pursuing their own interests including reading the newspaper, and crocheting. One said that they like to read the library books, and that someone had come to play draughts with them the previous day – ‘and I beat them!’ There was a flipchart in the lounge, for word games, and various games available including bingo. Clients from the adjoining Day Centre had gone on a day trip to the seaside, and residents who were well enough had been invited to join them.
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 14 The hairdresser was there for most of the day. She visits fortnightly, and uses the back lounge, where there was a sociable gathering. She also attends to people in their own rooms. Gentle musical exercise takes place twice a week, and a Tai Chi leader visits fortnightly to encourage exercise with silk scarves and feathers. Residents’ meetings are held monthly, in which ideas for activities and menus are discussed. Links with Moretonhampstead are maintained, with residents being taken to coffee mornings and other community events. The local Rector visits every month to give Holy Communion. The homes policy on ‘Visitors’ is included in the Service Users’ Guides and visitors are made welcome at any reasonable time. The residents may receive their visitors in one of the two communal rooms or in their bedrooms if they prefer. The inspector shared a meal with the residents, in the very pleasant dining room. Staff were seen to help and encourage residents to eat, as needed. Soft food was provided as necessary, and cups and plates designed to aid independence had been provided. The food was tasty, and very little was returned to the kitchen. Pudding included fresh fruit from a staff member’s garden. Suitable diets are provided for people with diabetes. The inspector asked some residents what they were expecting for lunch. None of them knew, but all were completely confident that they would enjoy it. The home owner has prepared new menus which will offer a choice of main course each day, following discussion with residents, and was planning to implement these in the near future. A tradition had been established of serving home made soup at tea-time, which residents were enjoying, and new recipes were being brought to provide an ever-increasing variety. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 15 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 good. Residents are protected by good procedures and practice within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and visitors to the home have access to the complaints procedure, which is displayed in the entrance hall and referred to in the Service Users’ Guide. No complaints or concerns have been reported to the Commission and no recent complaints had been recorded in the homes complaints book. Residents said that they would feel able to speak to any of the staff if they had any concerns – but said ‘I’ve never been worried’. Residents were protected by the home’s ethos of treating everybody with respect and consideration, as well as by its policies on adult protection and abuse. Staff had received training on abuse awareness. The Home owner and Deputy Manager are now aware of the procedure to be followed if ever there were an allegation of abuse, with reference to the Devon County Council’s Adult Protection Team. Incident records are kept of any behaviour by a resident that might put people at risk. Reviews of medication had been requested, and on-going progress monitored. It was advised that risk assessments should be recorded, including advice to staff on how to avoid risky situations, when a resident had a history of making unsubstantiated accusations. Holcombe House DS0000003722.V341419.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): 19,20,21,22,23,25,26 Quality in this outcome area is adequate. The home and gardens are well maintained, clean, well furnished and comfortable. However, there are safety issues that need to be dealt with in order to make the premises safer for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Holcombe House is a detached house on a hillside above Moretonhampstead. It has 17 bedrooms, four of which are large enough to be used as double rooms, two lounges, a dining room and a conservatory. Beside it are the Day Centre and the Home Owner’s accommodation. There is level access through the house, and a shaft lift to the first floor. A maintenance worker is employed two days per week. During this inspection he was repainting some of the fine windows, which reach to the floor in
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 17 downstairs rooms, giving some excellent views of the garden and surrounding countryside to people while they are sitting or even in bed. There were safety issues that still required attention. Some covers had been provided to radiators to prevent harm to residents if they fall against them, but some remain uncovered although they pose a potential risk. One was immediately beside the head of a bed. The Home owner said that the maintenance worker was building the covers individually, as the radiators vary in size and shape. These must be made a priority. Hot water in residents’ hand basins needs to be controlled by thermostatic valves to prevent risk of scalding. The Home owner said that the maintenance worker had fitted these in the downstairs bedrooms, but water was found to be running too hot in upstairs rooms. All portable electrical appliances had been tested, but the home’s wiring needed to be checked professionally. The dining room and back lounge had been redecorated in a calm shade of green, with a new washable carpet, contemporary lighting and most attractive curtains. The conservatory had also been recently redecorated, giving another alternative place to sit. Two pleasant areas of the garden had been made accessible for residents, though they will need to be accompanied, and a balcony can be accessed from the dining room. Further improvements to the surface of the area around the house would enable and encourage residents to enjoy the gardens and patios more easily. Residents’ abilities to benefit from a lock on their own door had been assessed, and one keypad lock had been provided. The Home owner said that other types of lock would be fitted if they would benefit the occupant. Residents’ doors had their name and a picture that had been chosen with them, or to please them, to personalise their room and help them find it. Pictures included cats, flowers and otters. There were two communal baths, one on each floor. Some residents have an en suite bath, but may not be able to use it, and some had been disconnected. The home owner was considering providing one or more accessible shower, which would be a benefit to residents, giving choice. Suitable locks should be fitted to bathrooms and communal toilets, because with the current bolts there is the possibility that staff might not be able to gain entry in an emergency. Liquid soap and paper towels should be provided in communal toilets. Staff are provided with their own hand-cleaning fluid, to carry with them. Nine of the bedrooms had en-suite toilet facilities. Sufficient toilets facilities are provided within close proximity of the communal areas and residents’ bedrooms. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 18 The laundry facilities were seen to be satisfactory, and there is a laundress who works Monday to Friday to ensure good care of clothes. The house was clean and sweet-smelling throughout. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 19 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. Staff are employed in sufficient numbers to meet the needs of the residents, the recruitment process is sound and appropriate training is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of staff rotas and conversations with the residents, staff and manager during the site visit indicate that the staffing levels maintained are high enough to meet the assessed needs of the residents. Newly appointed staff are required to complete an induction training programme which meets TOPPS standards. A programme that had been started was seen on the file of a recently appointed staff member. The Deputy Manager and a senior care assistant are currently completing their NVQ in Care at Level 3 and a further six members of staff are currently working towards or have gained their NVQ in Care at Level 2. This shows progress in the work to becoming a qualified team. Files had been prepared for each member of staff. The files of two recently appointed staff were examined, and it was seen that written references had been obtained and the Criminal Records Bureau clearance had either been obtained or applied for.
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 20 Certificates were seen on staff files to show that training had been provided this year in First Aid, Food Hygiene, and the Protection of Vulnerable Adults. Most staff had attended a training session on the care of people with dementia. This had dealt with diffusing and dealing with any aggressive behaviour. The staff would benefit from and appreciate further training, including Person Centred care. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,38 Quality in this outcome area is good. The home owner provides clear leadership and runs the home in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered service provider, Mrs Sue Owens, is also the Registered Manager of the home. She holds an Advanced Managers for Care Award (City & Guilds) and an ESCC Social Care Qualification. Her insistence on upholding good principles of care within the home assures that residents are treated well, and their dignity and individuality is observed. The Deputy Manager has been assisting in management tasks within the home, bringing an orderly approach to processes, to promote safe systems of work and good recording. The home is affiliated to a professional association who give advice on employment matters.
Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 22 There is not a formal quality assurance system in place, but feedback is gathered informally from residents and visitors, and monthly Residents’ meetings are held. One had occurred the week before this inspection, and the minutes kept showed that the new menus had been discussed, along with the provision of fruit juice and fresh fruit. Residents had expressed their enjoyment of certain of the afternoon activities that had been provided. One had said they enjoy the magazines, and there had been agreement that it had been a positive meeting. It is the policy of the home not to manage the resident’s finances but to ask the residents and/or their relatives to make their own arrangements for this if necessary. Any out of pocket expenses that the residents may have are either paid for by the home and billed to the residents’ representative or paid for in advance by the residents’ representatives. This system is recognised as good practice as it provides safeguards for both the residents and staff. The Deputy Manager had introduced useful supervision sessions with staff, offering them the opportunity to express their opinions as well as discussing their performance, ideas and practical problems. Records of a sample of these meetings were seen. Staff training and safe systems of work were in place. Issues potentially affecting the safety of the home and residents were included in the section on the environment. Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 23 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 3 X 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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 OP9 Regulation 13.2 Requirement There should be a way of recording the reason, when any tablet is not given. Variable dosage (PRN) tablets (such as pain killers) and non-prescription remedies should be recorded alongside the medication records, along with the reason for giving them and the dose given, for proper accountability. The registered person must arrange for the temperature of the hot water supplied to hand washing basins to be moderated through the use of valves as it is currently dangerously hot and people could be scalded. (Previous timescales 20.1.05, 5.6.05 & 5.11.05, and 08/06/06 not met) Radiators must be covered where there is a potential for harm to a resident. Timescale for action 31/08/07 2. OP21 13.4 31/08/07 3. OP24 13.4 30/09/07 4. OP26 13.3 The registered person must 30/09/07 provide safe hand washing facilities in communal toilets with liquid soap and paper towels.
DS0000003722.V341419.R01.S.doc Version 5.2 Page 25 Holcombe House 5. OP38 23.2 The electrical circuit must be tested professionally. 30/09/07 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 OP7 Good Practice Recommendations The care plans would benefit from a summary of the care that is required each day, in agreement with the resident. A personal profile or life history for each resident would help develop staff’s understanding of the person. An Occupational Therapy assessment should be sought on behalf of a resident whose mobility and balance had deteriorated. The surface of the area around the house should be further improved to allow residents easier access to the gardens and patios. Suitable locks should be fitted to bathrooms and communal toilets, because with the current bolts there is the possibility that staff might not be able to gain entry in an emergency. A quality assurance/quality monitoring system should be introduced to gain feedback from the residents, staff and other stakeholders about the quality of the service provided and to involve them in the ongoing development of the service. 2. 3. 4. OP8 OP19 OP21 5. OP33 Holcombe House DS0000003722.V341419.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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
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