Inspection on 08/05/06 for Holcombe House

This inspection was carried out on 8th May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Holcombe House 25/08/09

Holcombe House 17/07/07

Holcombe House 05/10/05

Holcombe House 04/05/05

Holcombe House 19/10/04

Holcombe House 21/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Holcombe House Butterton Lane Moretonhampstead Newton Abbot Devon TQ13 8PW Lead Inspector Judy Hill Unannounced Inspection 8th May 2006 10:00 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.V289570.R01.S.doc Version 5.1 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.V289570.R01.S.doc Version 5.1 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 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.V289570.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Holcombe House is registered to provide accommodation and care for up to twenty-one people (men and women) who are over sixty-five and who may have dementia and/or a physical disability. The home is situated on the outskirts of Mortonhampstead and has spectacular views over Dartmoor, but it is within walking distance of the town centre. A written Statement of Purpose is available for inspection 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.V289570.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report was gained from a pre-inspection questionnaire that had been completed by the owner/manager, two questionnaires completed by service users, one completed by the District Nursing Service, two completed by GP’s, two completed by relatives, the previous inspection reports and a visit to the home. During the home visit, the service provided to three service users was case tracked and this involved an inspection of records, conversations with the residents, with their key members of staff and an observation of their accommodation and facilities. Additional information was gained from direct and indirect observation, an inspection of further records, including staff rotas and menu plans and in conversation with other service users, visitors to the home, staff and with the registered owner, who also manages the home. What the service does well: The homes Statement of Purpose and Service Users’ Guides provide good information about the service. The quality of the care provided is good. The owner/manager and staff work well with the professional health care services to ensure that the service users health care needs are monitored and can be met. The service users medication is handled by trained staff, stored safely and conscientiously recorded. The staff treat the service users with dignity and respect. A range of social and occupational activities are organised by the home of a daily basis. There are no restrictions of visitors and the residents may receive their guests in the privacy of their bedrooms or in one of the communal lounges. The residents are able to exercise choice and control over their lives. The meals are well prepared and the residents are offered choices and alternatives to the set meals. Special medical diets can be catered for. The complaints procedure is accessible to the service users and visitors to the home and very few complaints have been recorded. Staff training in provided in adult protection and abuse and this, together with the homes written policies and procedures, protect the service users from abuse. The premises are kept clean, well decorated and comfortably furnished. The residents have a choice of two communal lounges and a sun lounge to sit in but are free to spend as much time as they wish in their bedrooms if they prefer to do so. The home has adapted bathroom facilities so that residents Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 6 with poor mobility can bathe safely. Ample toilet facilities are provided, some en-suite. The staffing levels are high enough to meet the needs of the residents and most of the staff are very experienced and well trained. The staff are helped and encouraged to gain NVQ qualifications. The owner/manager is well qualified and very experienced in the provision of care. She is highly regarded by the staff and residents and by the professional health care practitioners. What has improved since the last inspection? What they could do better: The recorded needs assessments and care plans need to be more detailed to provide evidence that each of the residents individual health, personal and social needs are fully identified and are being met. Residents who are confused and may be at risk of wandering must be provided with a safe outdoor area. Other safety issues that need to be dealt with include the regulation of hot water to hand washing basins, which are dangerously high and the provision of radiator covers, the safe storage of domestic chemicals, the removal of training bell cords, which could be a trip hazard. The residents should be provided with safe storage facilities and suitable locks should be fitted to bedroom doors, unless individual risk assessments have been carried out to demonstrate that this would not be in the service users interests. Safer staff recruitment practices, including gaining written references and commissioning enhances CRB checks, must be used to ensure that unsuitable staff are not employed to work with the residents. Although the overall provision of staff training is satisfactory, the owner/manager must ensure that training in First Aid and Basic Food Hygiene is kept up to date. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 7 A quality assurance system should be developed to enable the staff, service users and their representatives to have a greater input in the ongoing development of the service. 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. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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.V289570.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 The quality outcome for this area is adequate. This judgement has been made using available evidence including a site visit. Prospective service users and their representatives are given most of the information they need to make an informed choice about whether the service will meet their needs. However, the needs of prospective residents are not fully identified prior to admission therefore no assurance can be given to prospective residents and their representatives that the home will be able to meet their needs. EVIDENCE: An inspection of the homes Statement of Purpose and Service Users’ Guides provided evidence that both documents had been revised since the last inspection and now provide good information about the service for current and prospective service users and their representatives. Case tracking was used to inspect the needs assessment processes that are carried out by the home prior to admission. The internal needs assessments for three of the service users were seen and provided evidence that insufficient information is recorded about prospective service users to enable the home to give a written assurance that their needs can be met prior to admission. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 10 Despite the poor quality of the written assessments, conversations with the owner/manager, staff, residents and visiting relatives and questionnaires completed and returned from two GP’s, two relatives and the District Nursing Service indicated that the service is meeting most of the current resident’s needs. The need for more detailed and better organised written needs assessments was discussed with the owner/manager. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The quality of the health and personal care provided is good, but individual care plans need to be more detailed to ensure that the staff know and can meet each of the residents individual needs. EVIDENCE: Very positive feedback was received from the local District Nursing Service, GP’s and relatives of residents about the quality of care provided at Holcombe House. The care plans for three of the service users were inspected as part of the case tracking process and although the quality of the care plans that were seen varied considerably, but none of them were sufficiently recorded in detail. It was, however, noted that additional individual risk assessment and risk management strategies had been written up since the last inspection. Conversations with the owner/manager, staff and residents and an observation of the service users who were case tracked demonstrated that the manager and staff are aware of and are meeting most of their needs. The ability of the home to meet service users needs was further demonstrated in conversation Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 12 with two visiting relative, who said that they were very pleased with the quality of the care provided. Evidence was seen in the form of daily reports, the visitors book and service users files that timely referrals are being made to the primary and secondary health care services as and when necessary. This was confirmed in questionnaires completed and returned by two GP’s and the District Nursing Service. Two examples were singled out to demonstrate the quality of the personal care provided. These are continence control and the prevention of pressure sores. The pre-inspection questionnaire identified that the home has policies and procedures regarding continence promotion and although most of the service users are incontinent, none of the obvious signs of incontinence were detected during the home visit. The pre-inspection questionnaire stated that the home had recently updated its policies and procedures on pressure relief. Records were seen, including risk assessment and risk management strategy, to demonstrate that very good precautions are being taken to prevent the risk of service users developing pressure sores. The service users medication is kept in a locked medication cabinet and the pre-inspection questionnaire stated that policies are procedures are in place regarding the control, administration, recording and disposal of medication. Records were seen to demonstrate that the senior staff have received training in the administration of medicines and an inspection of the medication records and stored medication demonstrated that the arrangements in place for the administration of the residents medication are satisfactory. A member of staff who is the key worker of one of the residents who was case tracked was asked what the service users medication was for and was able to identify the conditions that each of his tablets were needed for. Very little non-prescribed medication is kept at the home and the manage and deputy manager were both aware of the need to ensure that ‘homely’ remedies were not used if they were not compatible with a service users prescribed medication. An observation of the interaction between the owner/manager and staff and the service users demonstrated that the service users are treated with dignity and respect. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Consideration is given to ensuring that the residents maintain some control over their lives and that they are given the opportunity to engage in social activities. The meals provided are very good although consideration could be given to extending more choices for residents who could benefit from this. EVIDENCE: The pre-inspection questionnaire that had been completed by the manager identified that regular in-house activities are arranged for the residents. These activities include musical exercise, musical entertainment, craft workshops and aromatherapy. The activities for the day are posted on a notice board and on the day of the site visit musical entertainment had been arranged. The residents can choose whether or not they wish to participate in the organised activities. Most of the residents have television sets and radios in their rooms and one of the service users spoken with said that he had daily newspapers delivered. The owner/manager confirmed that newspapers and magazines can be ordered on request and that although the residents had to pay for the paper or magazine, no charge would be made for delivery. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 14 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. During the site visit two visitors were spoken with and they said that they were very pleased with the care provided at the home and that they were always made to feel welcome by the owner/manager and staff. The ability of the residents to make choices in order to retain control of their lives was observed during the inspection. Examples of this included residents choosing whether to use the communal lounges or remain in their rooms and choosing whether or not to join in social activity planned for the afternoon. Most of the residents have dementia and would find it difficult to manage their own financial affairs. The registered person stated in the pre-inspection questionnaire that the home does not handle any of the service users personal financial affairs and that families or legal representatives are asked to provide help if assistance is needed. This was confirmed in conversation with a resident and visitors to the home. The menu plans provided show that the residents are offered a choice of meals for breakfast and high tea. The main meal of the day is provided at lunchtime, when the residents are offered a set dinner and a pudding. The kitchen staff know the residents dietary likes and dislikes and will provide alternatives to the set meal if required. Most of the residents have dementia and so may not benefit from being offered a choice of dinner in advance, but one resident who was not confused said that it would be nice consulted on a daily basis and asked what he would like to eat. The home is able to cater for people with special dietary needs, including diabetics and people who need their food pureed. For the later, moulds are used so that pureed food looks similar to food that is not pureed. The meals that were seen being prepared and served during the home visit looked very well prepared and feedback from residents indicated that the quality of the meals provided is very good. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is accessible but few complaints are recorded and there is no indication that the residents are not happy with the care provided. Written and accessible policies and procedures, coupled with the management and staffs awareness of abuse issues provides protection for the residents. 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. The pre-inspection questionnaire identified that the home has policies and procedures on adult protection and abuse and copies of these were seen in a file that is kept accessible to the staff. The owner/manager said that she, and five members of staff had attended a training course on adult protection and abuse and that a copy of the ‘No Secrets’ video had been obtained to provide further staff training on an in-house basis. Records showed that the deputy manager had attended course on challenging behaviour and a course on conflict management. This was discussed with her and she was able to demonstrate how this training had enabled her and the registered manager to develop good practice guidance for the staff, who do occasionally have to Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 16 defuse conflict between residents. Other staff spoken to during the home visit demonstrated a good understanding of adult protection and abuse issues. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 & 26 The quality outcome area for is adequate. This judgement has been made using available evidence including a visit to the service. The home and gardens are reasonably 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. EVIDENCE: Holcombe House is a detached period property that is set in fifteen acres of grounds on the outskirts of the small moorland town of Mortenhampstead. It is not far from the town centre, which has good health care and social facilities, although private transport facilities may be needed to access the town. Regular maintenance is carried out on the house and the gardens are well maintained. Apart from a small balcony that is accessible from one of the communal lounges, there is no safe and accessible area of garden available for use by residents who may be confused and at risk of wandering. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 18 The owner/manager was served with a letter of non-compliance by Devon Fire & Rescue Service in February 2006, and has since upgraded her fire prevention and associated fire safety precautions to meet the required standards. Although several of the resident’s bedrooms have en-suite bathrooms and shower rooms, most of the private baths and showers have been disconnected and/or are no longer in use. There are two communal bathrooms and although this is below the recommended minimum for a home with twenty-one residents, it is sufficient for the current service users, all of whom require staff assistance to bath or shower. The bath in the ground floor bathroom was seen to be suitable for use by people with physical disabilities and one of the residents spoken with confirmed that the bath was easily accessible, with help from the staff. Nine of the bedrooms have en-suite toilet facilities and additional communal toilets ensure that adequate toilets facilities provided within close proximity of the communal areas and residents bedrooms. The owner/manager said that the hot water provided to bathing facilities had been regulated to eliminate any risks of the residents scalding themselves but it was observed that the hot water supplied to hand wash basins was too hot to enable residents or staff to wash their hands comfortably with. Plugs are not always available to enable the hot and cold water to be mixed and so this does raise issues of health and safety. Although not all of the residents bedrooms were inspected on the home visit the rooms of the three service users who were case tracked were inspected. It was observed that radiator covers had not been fitted in all of the bedrooms, which could leave the residents at risk of scalding themselves. It was also observed that one service user did not have access to the call bell system from her chair and that the flex of another residents call bell ran across the room and presented a trip hazard. None of the bedroom doors are lockable and although it is accepted that most of the residents may not benefit from being able to lock their rooms, individual risk assessments had not been written up to justify this lack of provision. The residents are not provided with lockable storage facilities. The bedrooms seen were clean and comfortably furnished and had been personalised by the people using them. The laundry facilities were seen to be satisfactory. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to the service. Safe staff recruitment practices are not used and although the service users can be confident that the current staff team are trustworthy, experienced and well trained, unsuitable staff could be employed. 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 service users. Conversations with the staff and manager and an inspection of staff records indicates that the provision of staff training varies considerably between staff. Newly appointed staff are required to complete an induction training programme which meets TOPPS standards. It was observed that some of the staff had attended a very good range of relevant specialist courses, which is regarded as good practice, but that there were gaps in the basic areas of training, such as First Aid and Basic Food Hygiene which the registered provider is seeking to fill. The Deputy Manager and a senior care assistant are currently completing their NVQ in Care at Level 3 and a further three members of staff are currently working towards or have gained their NVQ in Care at Level 2. Most of the staff are very experienced and the staff turnover is low. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 20 The staff records relating to three members of staff were inspected. Each member of staff had completed an application form but two written references had only been taken up for one. An enhanced CRB check had only been commissioned for one of the three. Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. The owner/manager is very experienced and the resident’s benefit from her understanding and knowledge of good care practices. Some safe working practices were evident but improvements in the provision of some basic staff training and a risk assessment of the premises could improve the safety of the home for the residents. EVIDENCE: The registered service provider is also the manager of the home. She holds an Advanced Managers for Care Award (City & Guilds) and an ESCC Social Care Qualification. Before buying and managing her own home, she was employed both in a management and care worker capacity so has a wealth of experience in the provision of care. Training records seen during the site visit provide Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 22 evidence that the owner/manager regularly attends training courses to update her skills. There is no formal quality assurance system in place but conversations with the owner/manager identified that work was being carried out to identify a system that would suit the service. Feedback is regularly sought from the service users through residents meetings, for which minutes are taken, and through day-to-day contact with the residents. It is the policy of the home not to manage the resident’s finances but to ask the service users 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 service users representative or paid for in advance by the service users representatives, as witnessed during the site visit. This system is recognised as good practice as it provides safeguards for both the residents and staff. Some evidence was provided to demonstrate that same working practices are being carried out, for example the development of risk assessments, equipment and training to ensure that safe moving and handling methods are used and improvements in the fare safety equipment and associated fire precautions. In areas evidence of shortfalls were observed. Notably these are in the provision of basic training, gaps were seen in the staff training records regarding the provision of training in first aid and food hygiene, also in the provision of safe facilities to enable the residents and staff to wash their hands thoroughly (see Environment). During the site visit several bottles of bleach and other domestic chemicals were seen in the bathrooms and toilets, which should be stored safely to prevent accidents. The pre-inspection questionnaire identified that routine maintenance of the central heating system, safe safety appliances and gas installations was up to date. The water, which is from a natural source, is also regularly sampled for purity. The need was identified during the inspection to carry out and record a risk assessment of resident’s rooms to ensure that any avoidable risk factors can be identified and dealt with in an appropriate manner (see Environment). Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 4 X X 2 Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 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 OP3 Regulation 14 Requirement The registered person must ensure that detailed needs assessments are carried out for each prospective and existing resident, that these are kept in the service users case files and used to develop individual care plans. The registered person must ensure that the needs assessments (above) are used to develop individual care plans, where possible with the service users, detailing how the service users individual needs will be met. Recorded reviews must be carried out regularly. The registered person must provide an area of garden that is suitable for, and safe to use by, the residents who are confused and may be risk of wandering. (Previous timescale 5.4.06, not met) The registered person must arrange for the temperature of the hot water supplied to hand washing basins to be moderated DS0000003722.V289570.R01.S.doc Timescale for action 08/08/06 2 OP7 15 08/08/06 3 OP19 23 08/08/06 4 OP21 23 08/06/06 Holcombe House Version 5.1 Page 25 5 OP24 23 6 OP24 13 7 OP29 19 8 OP38 13 through the use of valves as it is currently dangerously hot and users could be scalded. (Previous timescales 20.1.05, 5.6.05 & 5.11.05, not met) The registered provider must ensure that each of the residents has a private lockable facility within their bedrooms. (Previous timescales 20.1.05, 5.6.05 & 5.11.05, not met) As a number of risk factors, in the form of trailing leads, unprotected radiators and scalding hot water were identified during the site visit, the registered person must carry out a risk assessment of the bedrooms, bathrooms and toilets in order to identify and remove avoidable risks to the resident’s safety. The registered person must use safe recruitment methods, including taking up references and obtaining enhanced CRB checks to ensure that unsuitable staff are not employed to work with the residents. The registered person must ensure that safe working practices are used and that the premises are safe. In particular this refers to the provision of training in First Aid and Basic Food Hygiene, the provision of safe hand washing facilities, and the safe storage of domestic chemicals. 08/06/06 08/06/06 08/06/06 08/06/06 Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 26 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 OP24 Good Practice Recommendations Suitable locks, which can be overridden by the staff in the event of an emergency, should be fitted to the resident’s bedroom doors unless it can be demonstrated through individual risk assessments that this provision would not be safe. Covers should be fitted to all radiators to eliminate the risk of residents scalding themselves. 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. OP25 OP33 Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holcombe House DS0000003722.V289570.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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