Inspection on 07/06/06 for Holehird - Leonard Cheshire Disability

This inspection was carried out on 7th June 2006.

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 no outstanding requirements from the previous inspection report, but made 8 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... 16/03/06

Holehird - Leonard Cheshire... 01/12/05

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 7th June 2006 09:45 Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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) www.leonard-cheshire.org.uk 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.V291292.R01.S.doc Version 5.2 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 16th March 2006 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 summer 2005, and is registered with CSCI. Leonard Cheshire announced in 2003 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. The weekly fees at Holehird are set in accordance with each service users’ assessed care needs. The range of fees for current service users ranged from £586.60 to £1006.62 per week. Information about the home, in the form of a service user guide, could be viewed at the home or copies requested. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A team of three inspectors carried out this unannounced inspection: Jenny Donnelly, Ray Mowat and Colette Hibbert. The inspection took place from early morning to mid afternoon, and consisted of a tour of the building, inspection of care, staff and service records, and discussion with service users and staff. The medicines were inspected and meal times and activities were observed. The registered manager and care supervisor for Holehird were present. CSCI had gathered written information from Holehird earlier in the year, and supplied comment cards for service users to complete, about living at Holehird. What the service does well: What has improved since the last inspection? Since the last inspection of March 2006 many improvements had taken place at Holehird. Care Plans (known as Individual service plans, or ISP’s) had been overhauled and a new system set up. The plans had been created with the input, and agreement of service users and were much improved. Through this system service users wishes had been incorporated in planning their health, personal and social care. The planning and provision of activities and opportunities for development had improved significantly. The record of controlled medicines was being accurately maintained, and care staff had ceased to administer medicines, as this is the responsibility of nursing staff. The key worker system had been redefined and those service users’, who wished to have a key worker, had been allocated one. A bathroom and toilet in need of repair had been upgraded. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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.V291292.R01.S.doc Version 5.2 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): 1 and 2 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. There is good information for prospective service users to make an informed choice about the home. Pre admission assessments are very detailed and linked to the fee structure. EVIDENCE: All service users at Holehird had undergone a detailed needs assessment prior to being offered a place in the home. These assessments were in depth, and included relevant information from other agencies, such as social workers, doctors, community nurses and specialist consultants. The home had good information for prospective service users and their families, in the form of a statement of purpose and service user guide. These were available to view in the home, or copies could be requested from the home. Service users were aware of these documents, and of Leonard Cheshire’s other information leaflets, including how to make a complaint, and what standards to expect from a Leonard Cheshire service. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Individual service plans set out each persons individual needs and wishes. These had been drawn up with service users, and demonstrated their choices and decision making. The plans were detailed and up to date with the exception of one. The actual delivery of care was not always consistent, depending on the staff on duty. EVIDENCE: Since the last inspection the staff had worked hard on producing new care plans, known as Individual Service Plans, or ISP’s. Four ISP’s were inspected in detail, and discussed with the service users concerned. The plans which were kept in service users’ bedrooms, were set out in order, were very detailed, up to date and gave an accurate picture of the service users’ needs and wishes. The plans included personal statements from service users where possible and demonstrated that people had been consulted and included in the drawing up of their plan. Health, personal and social care needs were included in the plans. Each service user who wanted had been allocated a key worker. Any areas of life that service users wished to manage independently, such as finances, medical appointments and social arrangements, had been recorded as such and their wishes respected. Where service users needed assistance, Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 10 the level of that assistance had been agreed and documented. Some service users were active in local disability rights groups, and other local and national organisations. One service user raised concerns about what staff wrote in their ISP, and this was discussed with the manager and head of care, to resolve with the service user concerned. The plan of a service user receiving respite care had not been updated between visits, and it was therefore not clear that the plan accurately reflected current needs. During conversations with service users, it was said several times that the delivery of care was variable, depending on which staff, and how many were on duty. This is further commented on under “Personal and Healthcare Support”. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home provided a wide range of activities and opportunities for service users, and had developed systems for identifying individuals needs and wishes. Service users were consulted on activities and assisted in the planning and organisation of events as they wished. The provision of meals was very good. EVIDENCE: Based on discussions with service users, and staff who are responsible for coordinating activities in the home, in addition to examining the home’s records and service user files, the shortfalls identified previously had been addressed. The home had three staff responsible for facilitating activities both in the home and in the local community. On admission to the home the activity coordinator completed a personal profile and a skills and activities section in the care plan. This recorded pertinent information about a person’s past life and what is important to them. It also included interests, hobbies and skills that people have and want to develop or maintain. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 12 The coordinator produced a weekly planner, which was displayed in the home to advertise what main activities were available each day. This was in addition to staff informing people on a daily basis what is available. The activity coordinators all work between Monday and Friday. At weekends a less structured approach was taken with at least one overseas volunteer providing additional support to people to pursue their interests. As well as the main advertised activities, service users were encouraged to pursue personal interests, including photography, computer work, gardening, reading, painting and nail care. There was evidence of these personal achievements around the home. As well as mental stimulation the home provided physical activities, which service users obviously enjoyed, including stretching exercises/yoga, indoor and outdoor bowls and table tennis. Some of these had been increased to two sessions each week at the request of service users. These have been adapted to accommodate people with severe disabilities, which is good practice. The home had access to three vehicles that have been adapted to accommodate wheelchair users. These were used when staffing levels allowed for community activities. Sometimes these were supported by one of the many volunteers. The home had free access to the lakeside steamer with trips to the shops or the garden centre also proving popular. The home has a fully accessible kitchen for residents to develop self-help skills to maintain or develop an independent lifestyle. This has also been adapted to accommodate people with physical disabilities. The service users computer has been moved out of a locked room into the main activities lounge and sited in an adjustable computer station. The manager plans to provide a further two computers in this area, to facilitate group tuition/assistance, which will be very beneficial to service users. The manager was also liaising with Kendal College to try and access support for any service users wishing to pursue further education. Progress in this area should be continued. From discussions with service users and through the completed comment cards, it was apparent that the quality and choice of meals was very highly praised. Daily routines were mostly flexible according to service users needs and wishes, but some service users felt this was affected by staffing levels at times. Also service users said they had to remind certain staff to address them politely. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The standard of personal and healthcare support was mostly good, but was not consistent. Service users sometimes had to remind staff of their needs and wishes. The management of medicines was satisfactory, with some areas for improvement. EVIDENCE: The service user plans set out in detail peoples’ preferences about how they wished their care to be delivered. The feedback from service users about their actual care delivery was variable. Service users stated that this was entirely dependant on the individual staff member who cared for them on any day. Service users said some staff were, “lovely”, “really great” and “have a very good attitude”. Service users also said they had to remind some staff to be polite and give regard to their dignity. One service user said “I am fussy about my morning routine and need it to be right, so I tell staff if it is wrong, because I can shout up for myself”. Another said, “it can take a long time to find two staff, so by the time I’ve been helped to sit up in bed, my meal is cold”. The standard of care was also reported to be dependant on the number of staff on duty, and this was said to be frequently low due to absenteeism. The staff rota confirmed there was a high incidence of staff sickness. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 14 Healthcare arrangements were good, in that the home had good relations with the local doctor who visited every other week to attend to any non-urgent medical needs. However service users again felt this was dependant on individual staff and whether they remembered to note down your request to see the doctor, or you had to wait for the next visit. The home has a well-equipped physiotherapy department, staffed by a fully qualified physiotherapist for 18 hours each a week. As reported previously, there is no physiotherapy assistant, and the physiotherapist relies heavily on care staff and volunteers to help her provide effective treatment. When staff levels are low this is not possible. The physiotherapist does a lot of work with service users suffering from bad chests, and in ensuring service users are positioned correctly to maintain their posture. She also carries out some occupational therapy duties, assessing for, and ordering equipment, and managing clinic appointments. Service users spoke highly of the physiotherapy treatment they received. The management of medicines was inspected and found to be satisfactory. Three service users managed their own medication, and had been provided with a locked facility to store it safely. Boots the chemist, supplied the medicines in a Venalink pre-packed system, along with printed medicine administration records (MAR). Further to last inspection, memos had been issued stating that care assistants are not to administer medicines, as nurses’ are responsible for this, and for assessing service users at that time. The storage and record keeping for medicines were mostly good, with a few items reported back to the manager and care supervisor for their attention. One medicine chart had been handwritten, but was not signed. Handwritten charts should be signed by the doctor, or by two staff, to confirm the prescrption has been copied out correctly. One dose of diazepam was unclear, as the dose had been changed but the supply was still for the origonal amount. There was no current list of medicines for a service user receiving respite care. One Venalink contained some broken capsules, which needed to be replaced. The stock and records of the controlled medicines were checked and correct. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The homes complaint system worked well for service users, with all concerns/ complaints being appropriatey investigated and responded to within a specified time. The protection of vulnerable adults arrangments were less clear, with staff not certain of the correct procedure to make a protection referal or implement the whistleblowing procedure. EVIDENCE: The complaint register was inspected, and showed that any complaints received had been fully logged, with the investigations and outcomes clearly recorded. Since the last inspection there were two new entries, both relating to staff grievances, not service user complaints. The home took staff concerns seriously under their grievance procedures, and this included protecting staff from racial abuse and harassment. Further to a previous requirement, the manager had attended the first session of the Leonard Cheshire protection of vulnerable adult training. The home had policies and procedures on the protection of vulnerable adults, but these were quite complex, and not well understood by staff. There was evidence that some staff were not clear about what was an acceptable way to behave with service users, and were not sure about their whistle blowing obligations. Further training is needed in this area. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The home provides a suitably adapted environment for people with physical disabilities. The home was clean and hygenic throughout, although cleaning materials were not always safely stored, and some minor repairs were needed. EVIDENCE: Holehird is a grade 2 listed building on both the inside and outside of the building. This can be problematical when trying to improve and modernise the environment. On the whole the home is well maintained, clean and hygienic, however some of the fabric of the building is dated and worn in some rooms. In particular, some carpet tiles are in need of replacement. It is recommended the home review their programme of repairs and renewal, and ensure worn carpets are replaced as required. The home has been adapted to accommodate people with physical disabilities and suitable aids and adaptations were in place. A good example of this is the kitchen/diner, which has work surfaces and appliances that are accessible to someone who uses a wheelchair. The home has a handyman who takes a lead role in maintaining a safe environment. Records were maintained in relation the maintenance and Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 17 servicing of equipment and services, these were examined and found to be up to date and in order. The home has a service contract for all lifting equipment and the water services of the home, the gas services had recently been inspected with an up to date landlord safety certificate in place. The home has extensive grounds, which are fully accessible and well maintained and provide a lot of pleasure to the residents. In a bedroom with secondary glazing it was noted that windows to the outside did not have a restrictor fitted, which could be hazardous. The home should assess this risk to residents and take appropriate action to eliminate the risk. Further to a previous requirement, one toilet and bathroom in need of repair, had been upgraded. The national minimum standards recommend that homes for younger adults be organised so that no more than ten people share a staff group, a dining area and other common facilities, by April 2007. Leonard Cheshire has long term plans to move out of Holehird, and provide alternative accommodation elsewhere. No recommendation is made on this standard as yet. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. Recruitment procedures were quite thorough but the home routinely employs staff prior to receiving a full CRB disclosure, which does not serve to protect service users. There was a good provision of staff training, but the home needs to increase the number of carers with an NVQ in care. Service users felt that some staff did not always demonstrate a good attitude, and thought the manager should spend more time around the home. EVIDENCE: Leonard Cheshire provides good staff training, and regional training managers facilitate this. Holehird has a training manager who plans all training, and delivers some of the sessions herself. Records of training are held on individual staff files as well as on electronic records. Training is provided either on site at Holehird or in Leonard Cheshire’s Warrington facility. The manager has been promoting more on site training, to reduce the need for travel. New staff undertake a three-month induction and trial period, which could be extended if competency concerns are highlighted. Staff had received mandatory training such as safe moving and handling, and fire safety. The training manager kept an electronic matrix for this, which automatically highlighted any overdue dates in red. All staff received equality and diversity training on disability. The national minimum standards call for 50 of care Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 19 staff to have an NVQ in care. Holehird currently has 27 , and is working on increasing this. The staff rota showed that the numbers of nursing and care staff on duty did fluctuate. This was in line with service users comments about staffing levels. The manager said that occupancy was reduced at this time, and staffing levels reflected that. There was a high incidence of staff sickness, and evidence from staff and service users that on some days the home was short staffed. As stated earlier in this report, the quality of care delivered varied depending, which staff were on duty. Both staff and service users commented that the manager should be “firmer with staff”, “spend more time out of the office”, “work more hands on, to see what goes on” and “be a working presence around the home”. Inspection of staff files found them generally to be in good order and complete. However, new care staff routinely started work prior to a criminal records bureau (CRB) disclosure being available. This is contrary to national guidance. In response to this, the manager confirmed that all new staff were checked against the protection of vulnerable adults register, worked in a supernumerary capacity for a week, then always worked in pairs and never alone. Inspectors were told that one staff member had recently had their employment terminated following the receipt of an unsatisfactory CRB disclosure. This was disappointing to service users who had built up a relationship with this carer, but also allowed an unsuitable person access to the home for a number of weeks. Supervision of care staff was the responsibility of the registered nurses, and there was a planning matrix in place highlighting when sessions were due. Three supervision files were inspected, the records were detailed and covered all aspects of work and training. Service users made some very favourable comments about certain care staff, and about all the kitchen and domestic staff, saying they were “ absolutely marvellous” and “would do anything for you – even if it’s not really their job”. The atmosphere in the home was light and cheerful. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. The managment arrangments for Holehird were satisfactory, although both service users and staff would like to see the manager spend less time in the office. There were systems in place to monitor the quality of the service, and health and safety arrangments were mostly satisfactory. EVIDENCE: The manager has been in post since summer 2005, and is registered with CSCI. Whilst staff said the manager was supportive, we heard many comments that he should spend more time out of office and see what goes on in the home. Holehird has a quality assurance system which includes periodic satisfaction surveys to service users. These were seen at the last inspection and gave mostly positive results. Some service users commented that they would like more daily contact with manager to share their views, rather than a once a year survey. As reported in the Environment section, the home was reasonably well maintained, with up to date service records. There were some Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 21 estates matters which needed addressing, including window restrictors and carpet tiles. Cleaning materials, subject to COSHH requirements (control of substances hazardous to health) were found in one of the sluice rooms and in a bathroom cabinet, which were accessible to service users. The home must ensure COSHH substances are securely stored at all times. Although theory fire-training sessions had taken place, there was no record of any fire drill or practice evacuation, which is recommended. Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 2 X X X 2 x Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA18 YA16 Regulation 12 Requirement Service users must receive personal support in the way they prefer and require, and their dignity must be maintained. Service users must be assisted to access healthcare in a timely manner. Handwritten medicine charts must signed by the doctor, or by two staff to confirm the prescription is correct. The home must keep up to date list of service users current medication. Staff must have a good understanding of adult protection procedures, and their whistle blowing responsibilities. New staff must not commence work prior to a satisfactory CRB disclosure being granted. Cleaning products subject to COSHH regulations must be safely stored. Timescale for action 31/07/06 2. 3. YA19 YA20 12 13 31/07/06 31/07/06 4. 5. YA20 YA23 13 13 31/07/06 31/07/06 6. 7. YA34 YA42 18 13 31/07/06 31/07/06 Holehird DS0000006133.V291292.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard YA12 YA24 YA24 YA32 YA39 YA42 Good Practice Recommendations The home should continue its’ work in accessing suitable education/training for service users. The home should review its’ programme of repairs and renewals, and ensure worn carpets are replaced. Risk assessments should be documented for first floor windows without restrictors in place. The home should work toward 50 of care staff having an NVQ in care. Further to comments received, the manager should make himself available more frequently to service users and staff. The home should carry out periodic fire drills. 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