Inspection on 15/07/08 for Holly House (Kettering)

This inspection was carried out on 15th July 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holly House (Kettering) 11/01/07

Holly House (Kettering) 08/08/05

Holly House (Kettering) 08/08/05

Holly House (Kettering) 28/02/05

Holly House (Kettering) 01/07/04

Holly House (Kettering) 08/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Holly House (Kettering) 79/83 London Road Kettering Northants NN15 7PH Lead Inspector Helen Abel Unannounced Inspection 15th July 2008 09:30 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 Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House (Kettering) Address 79/83 London Road Kettering Northants NN15 7PH 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) 01536 414319 C Mr Banesh Laxmilall Bhatoolall Mrs Zenaida Bhatoolall Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home will limit its services to the following service user categories: No person falling within the category Older Persons (OP) can be admitted where there are 5 persons of category OP already in the home. No person falling within the category DE(E) can be admitted where there are 26 persons in the category DE(E) already in the home. The total number of service users in the Home must not exceed 26. 2. 3. Date of last inspection 11th January 2007 Brief Description of the Service: Holly House Care Home provides personal care and support for up to 26 older people within the category of Dementia DE (E), to include up to 5 older people within the category OP. Mr and Mrs Bhatoolall are the registered providers of the Home, with Mrs Bhatoolall registered as the Manager. Holly House provides accommodation on three floors; the home is a conversion of a large detached residential property with accommodation within the ground, first and second floors. A passenger lift and stair lift provide access to the first and seconds floors for people with limited mobility. Holly House is situated close to Kettering Town Centre, and there is easy access to a range of community services and facilities. Service users healthcare needs are met by the community health care professionals The accommodation provides 8 single bedrooms, (6 with en-suite facilities) 9 double bedrooms, four communal sitting and dining areas, and an accessible enclosed garden. The current inspection report is available upon request from the office. The current weekly fee is £359.01 to £379.00. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for Service Users and their views of the service provided. This inspection was a ‘Key Inspection’ that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The primary method of inspection used was ‘case tracking’ that involved selecting three residents and reviewing the care that they received through inspection of the written information available on their care, such as the care plans (a care plan sets out how the home aims to meet the individual residents personal, healthcare, social and spiritual needs). Discussions took place with residents, staff, the registered manager and registered provider of the home. People living in Holly House prefer to be called residents. The inspector examined the last key inspection report, service history including complaints received, the annual service review and the annual quality assurance assessment. The inspection took place over a period of five hours during which the Inspector spent time observing the care of residents, examining care plans, policies and procedures and records in relation to staff training and recruitment, and upkeep of the home were viewed. The Inspector talked with a sample group of residents but had difficulty communicating with individuals due their health difficulties. Therefore two hours was spent just sitting observing residents in the communal areas of the home. A complaint was received in June 2008 and was investigated as part of this key inspection. All aspects were unproven. (See body of report complaints and protection). The registered manager Mrs Zenaida Bhatoolall and the registered provider Mr Banesh Bhatoolall were available at the home during the visit. Later that day a discussion was held on the telephone with the Inspector and registered provider. The quality rating for this service is 0 star. This means the residents who use this service experience poor quality outcomes. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 6 What the service does well: The admission process establishes the homes ability to meet the needs of people admitted to the home, prior to admission. Resident’s needs around health and personal care are met. A person centred plan of care is undertaken with the individual, relatives, and other health care professionals such community psychiatric nurses, district nurses and the general practitioners. Residents preferences and choices in relation to times for getting up and going to bed and times for breakfast continues to be based around residents wishes. One resident was seen to enjoy playing several games of dominoes, two other residents had a footbath, massage and foot cream applied. One resident read a newspaper and another resident did some colouring. A group of residents had their hair done by the hairdresser in the sun lounge. One resident enjoyed time playing with a teddy. Staff were observed sitting with quieter residents holding their hands and reassuring and taking to them. There was a pleasant warm friendly atmosphere with due attention being given to residents likes and needs. Communal areas were very clean and tidy, and well maintained. A sample of resident’s bedrooms was seen during the visit. All areas were comfortably furnished and rooms were personalised with resident’s belongings. It was noted pressure relieving equipment and moving and handling equipment, and bed rails are available for individuals. There is a core group of staff that who have worked at Holly House for a few years. This provides residents with familiar staff who know their needs well. The registered manager and registered provider are both qualified psychiatric nurses and have in-depth knowledge of the needs of the residents living at the home. The registered manager confirmed undertaking regular training and confirmed her clear leadership and management with clear lines of responsibility with team leaders that manage care staff on each shift. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: An Immediate Requirement was made for a breach in regulation around staff recruitment. New staff are confirmed in post following on the required checks have been carried out. This is to provide a safe environment for vulnerable adults. Staff would benefit from regular and ongoing training for: the administration of medication, adult protection, moving and handling, challenging behaviour and food and nutrition (for staff handling food). This would ensure residents are protected and their health safeguarded. Risk assessment for two residents to be updated, and a photograph of each resident held. This would provide staff with clear and full information when caring for individuals and ensure safe practice. Improved practise around the administration of medication; and resident’s personal care items, including toiletries and skin creams to be re-organised. Supplies of soap to be provided around the home. The laundry door should be kept secure. All these aspects would ensure a cleaner, safer environment and would help control the spread of infection. To ensure resident’s benefit with more meal choices, greater variety and wholesome meals are all recommended. Regular staff supervision to commence, to update the complaints procedure, and work on the quality assurance monitoring systems particularly for staff recruitment and adult protection. Please contact the provider for advice of actions taken in response to this Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 9 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 Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process establishes the homes ability to meet the needs of people admitted to the home, prior to admission. EVIDENCE: At the time of our visit a statement of purpose and service user guide are in the process of being updated. These documents are considered to be important sources of information for prospective residents and their representatives in helping them to choose a home. Without full information about the service and the type of care provided, prospective residents are unable to make an informed choice about moving into the home. The current inspection report is available upon request from the office. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 11 A sample check of residents care records identified that an assessment is carried out prior to admission to establish a prospective residents care needs. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs around health and personal care are met; and with improvements around medication management would ensure residents health care is further protected. EVIDENCE: Residents care files contain a comprehensive set of assessment and care planning documents. A person centred plan of care is undertaken with the individual, relatives, and other health care professionals such community psychiatric nurses, district nurses and the general practitioners (where relevant). All care plans were detailed and included general practitioner visits and other health professionals visits, weighing and toileting programmes, specific risk assessments and daily records. These documents are designed to guide staff in identifying and meeting the assessed needs of residents. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 13 The registered manager was reminded to ensure a photograph of each resident is held as required by legislation. Two residents used lap straps in their wheelchairs and in easy chairs to help keep them safe. The Inspector recommended this key information is included in individual’s risk assessment together with advice and guidance from relevant professionals. This will provide staff with full information when caring for these individuals and ensure safe practice. It was noted that a resident occasionally needed to sleep on the floor on a mattress for their personal safety and well being. This should also be included in the individuals risk assessment. Some residents were observed displaying challenging behaviour throughout the Inspectors visit. Their care records were often comprehensively recorded with information, regular reviews, and guidance from other professionals- the general practitioner, district nurse, and community psychiatric nurse. The Inspector observed staff caring for residents who were confused, shouting out and displaying outbursts, in a kind and gentle manner. The Inspector noted staff have not received any recent challenging behaviour training. The registered manager agreed and confirmed this would be arranged. The Inspector observed staff administrating medication to residents over a mealtime. It was noted that one resident was given their medicine, and told staff they would take it later. This was recorded on the medicines sheet as being administered. Two entries on the medicine sheets for two residents had been missed off. The registered manager will be investigating this further. Procedures around the use of medicine cups could be improved with labelling the containers for used and unused cups. This would ensure better hygiene practice. A large number of skin creams labelled and unlabeled were found in the ground floor bathroom cupboard. It was agreed with the registered manager that the cupboard would be re-organised; and staff should receive further training for medication management. This would safeguard resident’s healthcare. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle, interests, needs and preferences are well met. EVIDENCE: Residents preferences and choices in relation to times for getting up and going to bed and times for breakfast continues to be based around residents wishes. Throughout the morning many of the residents were observed undertaking activities with staff. One resident was seen to enjoy playing several games of dominoes, two other residents had a footbath, massage and foot cream applied. One resident read a newspaper and another resident did some colouring. A group of residents had their hair done by the hairdresser in the sun lounge. One resident enjoyed time playing with a teddy. Staff were observed sitting with quieter residents holding their hands and reassuring and taking to them. Daily activities undertaken are recorded in residents care Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 15 plans. There was a pleasant warm friendly atmosphere with due attention being given to residents likes and needs. The Inspector was unable to communicate with a sample group of residents due to their health difficulties, but spent dedicated time in the morning observing their interactions. On the previous weekend there had been an open day with strawberry cream teas served and all resident’s families invited. The Inspector observed a hot lunch being served in the dinning room and sun lounge. Special diets were also catered for. Staff were observed sensitively assisting individual residents to eat. The Inspector noted there was one meal choice available each day. Staff confirmed this was because people who lived in the home couldn’t make choices. The menu plan is rotated every two weeks but appeared to be very repetitive, although new menu plans were being considered with the cook. The Inspectors discussed providing choice and variety at mealtimes, and ensuring more balanced diets. The registered manager agreed to carefully consider these aspects. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are at not adequately protected. EVIDENCE: The complaints procedure is displayed in the statement of purpose but needs updating with the Commission for Social Care Inspection (CSCI) correct full contact details. The complaints procedure should also be included in the service user guide. The current draft does not include this. The registered manager agreed to do this. Since the last inspection in 2007 the CSCI has received one complaint in June 2008. Areas of concern were around health and social care and adult protection. These aspects were examined and discussed with the registered manager and registered provider on the day of the visit, and found to be unproven. Some good practice recommendations have been made (see end of inspection report). Some staff have received mental capacity act training this year. Many staff have not received recent adult protection training. To ensure residents are Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 17 protected from abuse, adult protection training this should be considered as part of the annual training programme. One staff member was working in the home before the required Vulnerable Adult checks had taken place. The Inspector made this an Immediate Requirement. The registered manager and registered provider confirmed this had happened on this one occasion. Providing safe recruitment practices will ensure vulnerable residents are protected from abuse. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a generally clean, fresh and comfortable environment. EVIDENCE: The Inspector found communal areas of the home to be very clean and tidy, and well maintained. A sample of resident’s bedrooms was seen during the visit. All areas were comfortably furnished and rooms were personalised with resident’s belongings. It was noted pressure relieving equipment and moving and handling equipment, and bed rails are available for individuals. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 19 New carpets have been fitted in all bedrooms, lounge, middle lounge, dinning areas, stairs and corridors. The plans for improvement over the next twelve months is to eventually change the curtains to match the carpets. This will provide a more comfortable environment for residents. A communal bathroom on the ground floor frequently use by residents, appeared untidy and poorly organised. Resident’s hairbrushes were pooled together in a cupboard, and on a windowsill in a container, and many appeared old, dirty and worn. A container of resident’s toothbrushes some dirty were tightly placed together. A wash bag overflowed with an electrical razor and various used wet razors. The Inspector noted there was no soap for hand washing in the laundry and staff toilet near the office. Unlabeled sponges used for foot and body washes were left piled together in a container. The lack of hygiene has the potential for cross infection between residents and staff. However disposable aprons, disposable gloves and disinfectant gel were in ample supply, and staff were observed using these when caring for residents. The laundry door was propped open with a brick. It is recommended the laundry area is kept secure as soiled articles, infected linen and cleaning materials are present and are a potential risk to residents. The registered manager agreed to look into this aspect and agreed this door should be kept closed. The garden area was used for drying washing on the Inspectors visit. The garden has new decking and patio slabs and new plants. The garden area is wheelchair friendly and residents were seen walking with staff and sitting in the garden. There are plans to obtain more plants, and outdoor tables and chairs for residents and visitors to sit on. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvements in the recruitment procedure will provide better protection for residents; and staff training needs to be improved to meet resident’s needs. EVIDENCE: There is a core group of staff that who have worked at Holly House for a few years. This provides residents with familiar staff who know their needs well. Staff training records were sampled. One staff member was on three months Induction but had not received any mandatory training for example around moving and handling. The registered manager was in the process of organising this for all staff and was a waiting training dates. One staff member had received Parkinson’s awareness training and was reported to find this useful when dealing with a resident with this condition. Another staff member did not receive regular supervision. It is recommended staff supervision takes place regularly to ensure staff are trained and Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 21 competent to do their jobs. The registered manager accepted this and will be ensuring more regular supervision for all staff. Another staff member confirmed with the Inspector previous training, but had received no new training in the last 12 months. All staff have National Vocational Qualifications. The registered manager aims for all staff to be and to continue having refresher courses and to employ extra staff. Staff told the Inspector, “I have supervision meetings with my manager.” “We have group meetings every month for all staff they are really useful.” Staff recruitment records were sampled and an Immediate Recruitment around a staff member working in the home before the required Vulnerable Adult checks had taken place. Residents must be supported and protected by the homes recruitment policy and practices. (See Complaints and Adult Protection). Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and welfare of residents are adequately protected by management arrangements, but residents would benefit from improved quality assurance systems. EVIDENCE: Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 23 The registered manager and registered provider are both qualified psychiatric nurses and have in-depth knowledge of the needs of the residents living at the home. The Inspector noticed residents warmly acknowledged the registered manager and registered provider when they arrived in the morning. Time was spent taking with and greeting residents. The registered manager confirmed undertaking regular training and confirmed her clear leadership and management with clear lines of responsibility with team leaders that manage care staff on each shift. The registered manager confirmed firmly upholding the values of person centred care and is committed to improving the management systems for the benefit of the residents. A staff member confirmed attending monthly meetings when all the staff get together, and felt this was useful and helped to learn about people living in the home and their conditions associated with old age. The accident recoding book was viewed concerning resident’s case tracked by the Inspector. Monitoring of accidents takes place to ensure the health and safety of residents. All the required health and safety checks have been confirmed completed. A handyperson is employed and was observed maintaining the garden and taking to residents in the garden. Staff recruitment and adult protection areas were identified on this visit as less secure and need to be reviewed as part of the homes quality assurance system. The registered manager did not confirm in the annual quality assurance assessment, the next twelve months development plan. This should include plan, action and review, and reflect aims and outcomes for residents. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 24 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 1 3 x 3 x x x x 1 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 x x 3 x 3 Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13 Requirement Timescale for action 22/08/08 2. OP9 13 3. OP18 19 To ensure unnecessary risks to residents. Risks assessments for the identified two residents should be revised to include aspects around restraint and sleeping arrangements. This will provide staff with full information when caring for these individuals and ensure safe practice To safeguard resident’s 15/08/08 healthcare. Staff responsible for giving medicines must receive further training for the administration of medication. Staff must be confirmed in post 15/07/08 following on the required safe checks. Completion of a Protection of Vulnerable Adult (POVA First) and Criminal Records Bureau (CRB) check. This will ensure residents are protected from abuse. An Immediate Requirement was made. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 26 4. OP26 13 5 OP33 24 These hygiene aspects should be 15/08/08 re-organised in order to maintain a cleaner environment to reduce the spread of infection to residents:Organise individual residents personal care items, hairbrushes, razors, and toothbrushes appropriately. Organise sponges /flannels for foot care for individual residents. Provide soap in the laundry and staff toilet areas; and for the food handler (a pump soap is preferable). The registered manager must 30/09/08 confirm in their quality assurance monitoring systems (and in the Annual Quality Assurance Assessment AQAA) for the next twelve months a plan for Staff Recruitment and Adult Protection. This must plan, action and review, and reflect aims and outcomes for residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered manager was reminded to ensure a photograph of each resident is held as required by legislation. This is to ensure residents record keeping is kept up to date. To ensure improved medication management: Review the medicine cups and organise skin creams in the ground floor communal bathroom. This would safeguard resident’s healthcare. To ensure residents benefit from more varied and DS0000012819.V368449.R01.S.doc Version 5.2 Page 27 2. OP9 3. OP15 Holly House (Kettering) 4. OP16 5. 6. 7. OP18 OP26 OP30 8. OP30 wholesome meals. To consider: Providing two dishes at each meal to allow individual residents some decision making and choice (where possible). To ensure food handling staff have a awareness of providing nutrional-balanced meals for older persons with additional learning and support provided. Consider providing a wider range of roast meals each Sunday to ensure variety and choice for residents. The complaints procedure to be updated on the complaints procedure displayed in the home, and in the statement of purpose, service users guide. This should include the Commission for Social Care Inspection (CSCI) full contact details. This information will ensure residents, their relatives and friends, will be confident their complaints will be listened to and acted upon. To ensure residents are protected from abuse adult protection training should be considered part of the annual training programme. Ensure the laundry is kept secure as soiled articles, infected linen and cleaning materials are present and are a potential risk to residents when entering this area. To ensure residents are protected and staff are well trained to provide- moving and handling and challenging behaviour training as part of the annual training programme. It is recommended staff supervision takes place regularly and is recorded, to ensure staff are trained and competent to do their jobs. Holly House (Kettering) DS0000012819.V368449.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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