Inspection on 01/12/05 for Holehird - Leonard Cheshire Disability

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holehird - Leonard Cheshire... 10/09/07

Holehird - Leonard Cheshire... 07/06/06

Holehird - Leonard Cheshire... 16/03/06

Holehird - Leonard Cheshire... 21/12/04

Holehird - Leonard Cheshire... 18/08/04

Holehird - Leonard Cheshire... 22/01/04

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

CARE HOME ADULTS 18-65 Holehird Lake District Cheshire Home Patterdale Road Windermere Cumbria LA23 1NR Lead Inspector Jenny Donnelly Unannounced Inspection 1st December 2005 09:30 Holehird DS0000006133.V259631.R01.S.doc Version 5.0 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 Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holehird Address Lake District Cheshire Home Patterdale Road Windermere Cumbria LA23 1NR 015394 42500 015394 45707 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) Leonard Cheshire Vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (6), Physical disability (23) of places Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of places providing nursing care must not exceed 22. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection by 30th September 2004 21st December 2004 Date of last inspection Brief Description of the Service: Leonard Cheshire operates Holehird. The building is a Victorian mansion, with a modern extension and is situated about two miles from the town of Windermere. It is set above the lake with beautiful views of the lake and the surrounding mountains. There is a large car park and adjacent public gardens, which are managed by the Lakeland Horticultural Society. The home has two floors served by a passenger lift, and residents’ bedrooms are situated on both floors. The communal and recreational rooms are on the ground floor. There is a physiotherapy room, and the home has been adapted with overhead hoist tracking in the majority of bedrooms and bathrooms. The manager Alan Barton had been in post since the summer, and had applied to be registered with CSCI. This process is not yet complete. Leonard Cheshire announced two years ago that they intended to move out of the Holehird building over the next two to three years, and provide a new purpose built home in a different location. There has been no further information on this. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors made this unannounced visit to Holehird between 09.30 and 16.30 hours. During this time we toured the home and spoke with people. Residents were spoken with throughout the day, both in the public areas, and in private. We also spoke to staff members and volunteers. Care plans were studied, and the storage and records of medicines were inspected. Other records relating to maintenance, staff recruitment and staff training were also seen. We observed the general running of the day, including meal times, drinks rounds and organised activities. Time was spent in discussion with the manager and head of care, about the finings of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Some residents felt Holehird was not meeting their needs, in that they had no control over their lives and they were bored. The residents that were not taken out by volunteers or family, had difficulty getting out of the home. There was lack of structured personal development and fulfilment for some younger residents. Care records were not detailed enough and some were out of date. The nursing input to care plans was lacking in some cases. Staff said the key worker system was not working because of a lack of time. Residents did not feel they gained any benefit from their key worker. Senior staff were on duty at the same times, so the skill mix was poorer at other times. Recruitment practices were poor. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 6 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. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A EVIDENCE: No standards in this section were assessed at this inspection. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Individual plans were not all fully complete; some lacked essential details and had not been updated for a while. While some residents were able to lead a very independent lifestyle and make their own decisions, others felt they were constrained and lacked choice. EVIDENCE: Leonard Cheshire introduced a new style care plan at Holehird, called an Individual Service Plan (ISP), about eighteen months ago. Whilst the format for these was comprehensive, it was disappointing to see that not all residents’ care plans had been transferred onto the new format. We studied a sample of ISP’s closely and found them to lack detail or a real sense of the person they were about. One plan had blank sections under the headings for “service user feedback”, “skills and interests” and “personal support”. The short, medium and long-term goals for one resident were to continue with visits from and to family. One residents’ behaviour plan was blank despite a problem behaviour being recorded. One plan had been dated as last reviewed in January 2004. Discussion with staff showed they did not know some residents’ history, and what had been important in their lives before they became disabled. This was simple information that we gained during short conversations with residents. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 10 There was a lack of nursing input in some plans, and a lack of risk assessments. The more able residents made their own decisions about how they lived, and what risks they took. They said they made their own arrangements with friends or family to come and go from Holehird, as they liked, and do what they chose on a daily basis. The more dependant residents needed assistance from staff to do this, and were therefore quite limited in exercising choice. One resident said he was not allowed to make decisions, and his life “was run for him”. Some residents were not being supported by staff to make their own decisions, or to live an independent a life as they could. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, and 17 While there was a good provision of regular in-house activities, there was not enough emphasis on personal development or education for younger residents. There were very limited opportunities for some residents to go out of the home into the community. The provision of meals was excellent. EVIDENCE: The lifestyle experience for residents living at Holehird was not consistent. Some residents had plenty going on in their lives, where as others had very little. It was the residents who needed the most support from staff who had the least opportunities for social and personal development. There was little in the way of age, peer and culturally appropriate activities for the younger residents. There did not appear to be any opportunities for younger residents to take up further education or vocational skills. Neither was there any evidence of personal development, long-term goals or aspirations for younger residents. There was a lack of fulfilment, and little opportunity to develop practical life skills. One resident said there was nothing to look forward to and it was “boring”. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 12 Holehird residents had their own communal computer. This was kept in a locked room, at the request of the residents’ committee. One resident held the key, but other residents seemed uncertain whether they were allowed access. The home had activities staff covering five days per week. They worked in the large activity room and offered a variety of round the table pastimes. There were quizzes, newspaper reading, discussions, flower arranging and arts and craft. Some residents really enjoyed these activities and looked forward to them greatly, while others preferred just to watch. There were photographs on display, showing residents taking part in a summer barbeque in the grounds, and on a boat trip. Holehird had two groups of volunteers. There were some young overseas volunteers, who lived on site and stayed for several months. They helped out around the home and assisted in the activities lounge, but were not able to take residents out, as they did not drive. The other volunteers were local people who had a longstanding relation with the home. These local volunteers were able to take residents out as long as they had the driving qualification required by Leonard Cheshire. Some residents could not go out with volunteer staff, as they needed care staff in attendance. This meant that certain residents benefited greatly from the volunteers, while others received little or no input from them. One member of care staff she had taken a resident out clothes shopping on her day off, otherwise this resident would not get to go out. Of the residents spoken to one said he did not get the chance to go out very much, and felt this was a “poor do”. He had no weekly plan for activities or social stimulation. Another residents’ weekly social plan was for a volunteer sit with him and share a cup of tea one day each week. Another felt she was lucky as visitors took her out regularly. Several local volunteers occupied another resident for the whole duration of the inspection. Since the last inspection, a new cook had been employed. Residents spoke highly of the food saying, “the food is very good”, “the meals are excellent”, “there is a good choice” and “they will do me something different if I ask”. Lunchtime was well organised with plenty of staff and volunteers present in the main dining room, to help as needed. There was adapted cutlery and special plates for those who needed it. Residents with swallowing difficulties had chopped, soft or pureed meals according to their need. A couple of residents chose to eat their meals in the conservatory, away from the business of the main dining room. The meal looked and smelt lovely, and although there were two choices on the daily menu, four different meals were seen being served. The cook was knowledgeable about residents’ food preferences and any special dietary needs. The kitchen was clean, tidy and well organised. The meals were the highlight of the day for some residents, and were clearly very much enjoyed. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents had a choice about how and when their personal care was delivered, but the key worker system was not working so well. Healthcare arrangements and the management of medicines were adequate. EVIDENCE: For personal support most residents said they had a choice of when to get up and go to bed. When we toured the building at 10 am, a small number of people were still in bed at their choice. One resident said he liked to get up early and go to bed late, and staff helped him to do so. Another resident said he got himself up, and did this when he wanted. There was evidence that service users chose the clothes they wanted to wear, and the ladies had their hair as they liked. However, one young male resident was expected to shave daily although he preferred not to, as he wanted “designer stubble”. Residents had the necessary equipment they needed, including special mattresses, personalised wheelchairs and hoists. However, we noticed that one resident’s wheelchair seat cushion was a few years old and this should have been replaced. The manager said four new beds had been purchased. Holehird employed a physiotherapist who worked four days a week. The head of care said the physiotherapist treated most residents, but some chose to see Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 14 a different therapist by private arrangement. There was no physiotherapy assistant, which limited the service for the residents who required two people. The home had a “key worker” system, whereby residents were allocated a carer to give them special attention. The manager said that some residents did not have a key worker, because of recent staff and resident changes. Some long-term residents did not know their key worker, and others did not think their key worker did anything special for them. Care staff said they did not have time to carry out key worker duties, as they were too busy. Residents were not benefiting from the key worker system. Medication was well organised in a new clinical room. Staff had gained permission from the doctor to crush certain medicines that were given via a feed tube. There was a written procedure on how to do this. Medicines were supplied monthly in blister packs, with separate bottles for liquids and periodic medicines. The management of medicines was mostly satisfactory with some room for improvement. Some spare medicine needed to be returned to the pharmacy. Some disposed of medicine had not been accounted for in the record. Some medicines had been given out of sequence, and the disposal register needed to be signed by two staff. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 There was a complaints procedure in place that worked well, and residents could raise any general issues through the residents committee. Staff had received training on adult protection (abuse), and were aware of their role in protecting residents from abuse. EVIDENCE: Leonard Cheshire had a full and detailed complaints procedure in place. This explained how to make a complaint and what response to expect. The new manager knew about this, and had responded to two complaints since he started the job. One compliant was in relation to missing property, which was resolved. The other was in relation to care and was partly upheld, and the complained about practice had changed. Residents varied in their understanding of how to make a complaint or raise a concern. Whilst some residents were well aware of the system, others said they didn’t know what they would do, but agreed they would speak to a staff member. One of the volunteers said the complaint process was too formal and longwinded. Residents could express their views through the residents committee. The committee held meetings and gave feedback to the manager on any issues that they wanted addressing. Sadly the residents’ committee membership had dropped over the last year, so it was not quite so representative of all residents. One resident said these meetings “didn’t happened very often now”. All staff had completed the Leonard Cheshire training on the protection of vulnerable adults (abuse). This subject was covered during the basic induction, and was followed by a more thorough training session and regular Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 16 updates. The manager had not yet done this training, but was expecting to do it in January. It is important for the manager to understand both Leonard Cheshire, and local multi-agency procedures for the protection of vulnerable adults. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 27, 28 and 30 Holehird provided a good environment for residents to live in. Residents were happy with their bedrooms, and had upgraded bathrooms and spacious toilets to use. There was plenty of communal space allowing good wheelchair access. EVIDENCE: Residents’ bedrooms were pleasant and provided with sufficient furniture. Due to the nature of the building, bedrooms were individual in size and shape, varying from 12.5 to 31 square metres. Residents liked their bedrooms and were pleased to give us a guided tour of them. Some residents had chosen their own décor and fabrics, and purchased their own furniture to suit the room. Several bedrooms had been decorated since the last inspection and had new carpets fitted. Residents who wanted to, locked their door, and had a doorbell or knocker in place. Further to a previous requirement the ground floor shower room had been refurbished. This now provides a pleasant, clean and safe showering area, suitable for taking a full-length shower trolley, with an overhead hoist track. Another bathroom had a new hi-low bath installed, which made much better use of the space, and was easier for staff to operate. There seemed to be some problem with the toilet roll holders around the home, as in most toilets Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 18 the paper was on the floor, or balanced on the toilet brush. The manager agreed to look into this. The communal space at Holehird was ample. There was a large open plan space comprising of an activity area leading on one side into two dining areas, and on the other side to a craft area and spacious conservatory. There were also two small sitting rooms at the other end of the building, but these were quite a distance from the hub of the home where staff were situated. Whilst being good for wheelchair access, the open plan layout and size of the communal space did not promote a homely feeling. The home was reasonably clean, and there were no unpleasant smells. A shortage of domestic staff meant that periodic in depth cleaning had not taken place. The manager was hoping to get contract cleaners in to do this. The housekeeper was on holiday, and one domestic was off work, leaving just one person to keep the whole building in order. There was also a domestic staff vacancy. Laundry was done in house, and there was a well-equipped laundry for this purpose. Residents had a laundry basket in their bedrooms and their laundry was done weekly on a set day. We asked about residents wet or soiled laundry being left in their baskets until washday, but care staff were said to deal with this immediately. The laundry staffing was for two hours an afternoon, which did not seem sufficient, and meant carers being away from residents to do emergency laundry. The manager however, said this system worked satisfactorily. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 and 35 Some residents benefited from the Holehird volunteers whilst others did not. The key worker system was not working well, and there was not a good spread of senior staff hours throughout the week. Staff training was good, but recruitment procedures were not. EVIDENCE: The manager said the staff team at Holehird had been fairly stable since he commenced in post, with very few changes. With the home having so many volunteers, it was difficult to tell if volunteers were carrying out duties that should be done by paid staff. We felt that the manager should take a more active role in allocating what volunteers do, to ensure they do not carry out inappropriate duties, and to ensure all residents receive an even share of their time. Staffing on this day comprised of the manager, head of care, one nurse and 7 care staff. There was also catering, domestic and administrative staff. The home used to have 8 care staff during the morning, but had reduced to 7, as there were fewer residents. Staff did not feel this gave them sufficient time to spend with residents, or to carry out key worker duties. We were concerned that the two senior staff, the manager and head of care, worked the same hours. This was roughly 9am to 5pm, and to 9am to 3pm respectively, Monday to Friday. This meant there was no management Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 20 overview of the 24-hour care period, and during the majority of the weekly hours there was no senior on duty. Staff said there had been no staff meeting for a long time. We were also told some night staff had not met the new manager, although the manager said he had been at the home on some evenings. Leonard Cheshire had good recruitment procedures in place, but inspection of some staff files showed they had not been followed. Two of the three files seen for care staff that started work in August, contained only one reference, not two. This was particularly worrying as neither of these staff had a criminal records bureau (CRB) disclosure yet, although these had been applied for. The regulations only allow staff to commence work without a CRB as long as other criteria are met, two satisfactory references being one of them. Other than this, staff files were in good order, and were much improved from previous inspections. Leonard Cheshire has a full training department, and the North West training officer was at Holehird on the day of inspection. There is a programme of training sessions that staff must attend, and these are run on a regular basis. Care staff confirmed they had completed the set training sessions, and that regular updates took place. The training records were not inspected, as they are held on computer, and will be checked next time. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 A long period of temporary managers had unsettled both residents and staff. This has been made worse by the uncertainty of future plans for the home. The services and equipment at the home were being maintained. EVIDENCE: The new manager has applied to be registered with CSCI, and this application is progressing. The requirement to have a registered manager will remain until the process in complete. The manager said he had commenced the Registered Managers Award course at a local college. There has been no registered manager at Holehird for approximately 20 months. During this time there have been temporary arrangements in place. Whilst this has satisfied CSCI in the short term, it has been unsettling for residents and staff. Of greater concern to residents and staff was Leonard Cheshire’s announcement two years ago to withdraw from the Holehird building. There has been no further clear information on what the future will Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 22 be like, or when changes are to take place. This has created an atmosphere of uncertainty and worry for both residents and staff. Leonard Cheshire has a quality assurance department, which takes periodic reviews of Holehird. Satisfaction surveys were ready in the office, to be sent to all residents. The questionnaires were very comprehensive and covered all areas of the service. The manager said he was looking forward to seeing the results of the survey, as they will guide him towards any improvements needed. Maintenance records were inspected and showed that routine servicing of equipment had either taken place or was planned to take place. Fire safety systems had been checked, and staff had received a fire safety update. Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 3 3 3 X 3 LIFESTYLES Standard No Score 11 1 12 1 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 X 2 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holehird Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 1 2 3 X X 3 X DS0000006133.V259631.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 Regulation 15 Requirement Residents’ care plans must be fully complete and up to date. Residents’ must be able to make decisions about their lives, and have opportunities for personal development and education. Residents must be provided with the equipment they need, and this must be functioning. Medicine disposal records must be accurate and signed by two staff. Staffing must meet residents’ needs, and the skill mix must ensure consistency of care delivery. Two satisfactory references must be taken up prior to new staff working in the home. The home must employ a suitably qualified and experienced manager, who is registered with CSCI (Previous timescales of 31/12/04, and 31/03/05 not met) Timescale for action 01/03/06 01/03/06 YA7YA9YA11 12 (2) 3 4 5 YA19 YA20 YA33 12 (1) 13 (2) 18 (1) 01/03/06 01/01/06 01/01/06 6 7 YA34 YA37 19 (1) 8 and 9 01/01/06 01/03/06 Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 25 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 Refer to Standard YA18 YA23 YA31 YA33 YA38 Good Practice Recommendations The key worker system should be more effective. The manager should attend protection of vulnerable adults training. The manager should ensure volunteers do not undertake the work of paid staff, and are of benefit to all residents. Staff meetings should be held at regular intervals Residents and staff should be kept informed of the future plans for Holehird Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Holehird DS0000006133.V259631.R01.S.doc Version 5.0 Page 27 - 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. 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