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Inspection on 16/03/09 for Holly House (Milton Malsor)

Also see our care home review for Holly House (Milton Malsor) for more information

This inspection was carried out on 16th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home understands the importance of having enough information when choosing a care home. Pre admission documentation was in place, and was being used effectively for prospective admissions to the home, to ensure that their needs could be met efficiently in this home. Residents are welcome to visit the home prior to making a decision about admission, however when this is not possible, families are encouraged to do so on their behalf. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with residents and their representatives. Medication records were accurate and in good order, contained the required entries and been signed appropriately by staff. An internal audit process was in place to support the system. People who live in this home are encouraged to maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and people are supported to make individual choices within their daily lives. This home provides a clean, comfortable and safe environment for the residents who live here. Recruitment procedures are fully adhered to so that residents are protected.

What has improved since the last inspection?

Since the last inspection all staff have attended further safeguarding training. The kitchen, which had caused some concern at the last inspection, was very clean. It had been painted and old condemned equipment removed. Fridge and freezer temperatures were being monitored and recorded daily, and the broken freezer seen at the last inspection had been replaced. Unused furniture, such as mattresses and mobility aids, that were previously being stored in an unused bathroom have now been removed. This service recognises the importance of training and delivers a programme that meets the National Minimum Standards. Records indicated that the manager has started to carry out supervision with all staff every two or three months.

What the care home could do better:

Since the last inspection the manager had been reviewing the care plans more frequently but still not monthly. One file had been reviewed on the 28/9/08, just afterthe last inspection, then on the 30/10/08, however a three month period past and it was not reviewed again until 30/01/09, and then 14/3//09. This service has a complaints policy on display and easily accessible to residents and visitors to the home, however records of investigations and responses to complainants are not always recorded on file. Since the last inspection all staff have attended further safeguarding training. The manager has also resourced a copy of local safeguarding protacols and incorporated this into his own policy. However the content and guidance in the policy need some clarification in places to ensure that information is not ambiguous, and staff have clear directions to follow in the reporting of safeguarding referrals. Checks show that record keeping is improving, however there are some gaps and omissions, and some entries are not always clear. Records indicated that the manager has started to carry out supervision with all staff every two or three months. At present this is only in the early stages, and this system needs time to establish a regular pattern to ensure that all staff are recieving six sessions each year. All records in this home are now being securely stored in a locked cabinet. They were in good order and risk assessments were in place to promote the safety of all the residents living in Holly House, however review processes could be improved.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Holly House (Milton Malsor) 36 Green Street Milton Malsor Northampton Northamptonshire NN7 3AT     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Louise Trainor     Date: 1 6 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Holly House (Milton Malsor) 36 Green Street Milton Malsor Northampton Northamptonshire NN7 3AT 01604859188 01923840278 info@hollyhouseresidential.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Parvin Kumar Menon,Mrs Madhu Menon care home 22 Number of places (if applicable): Under 65 Over 65 22 22 dementia old age, not falling within any other category Additional conditions: 0 0 Holly House (Milton Malsor) care home is registered to provide personal care to male and female service users who fall within the following categories: Old age: not falling within any other category (OP) - 22 Dementia: over the age of 65 years (DE(E)) - 22 The maximum number of persons to be accommodated at Holly House (Milton Malsor) is 22 Date of last inspection Brief description of the care home Holly House is a residential care home situated in the village of Milton Malsor, south east of Northampton. The home provides care for 22 older people. The premises consist of a detached house, and all rooms are single with en-suite facility. A service users guide to the services the home offers is supplied to applicants and the last Inspection Report is available on request. 2 6 0 9 2 0 0 8 Care Homes for Older People Page 4 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in accordance with the Commission for Social Care Inspections CSCI policy and methodologies which require review of the key standards for the provision of a care home for older people that takes account of service users views and information received about the service since the last inspection Evidence used and judgements made within the main body of the report include information from this visit This was the second Key Inspection for this year for this service. Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson carried it out on the 16th of March 2009 between the hours of 14:00 and 18:00 hours. Care Homes for Older People Page 5 of 29 The home owner/manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit During the inspection the care of three people who use this service were case tracked. This included a recent admission to the home. This involved reading their records and comparing what was documented to the care that was being provided Documentation relating to staff recruitment, training and supervision, and medication administration, complaints and health and safety in the home were also examined. We also spent some time in the communal areas of the home talking to staff and residents, and observing the care practices including, the service of the evening meal, that took place during this four hour inspection hour inspection by two inspectors. The fees for this home are presently between 359.00 pounds - 525.00 pounds per week. We would like to thank everyone involved for their support and assistance during this inspection. What the care home does well: What has improved since the last inspection? What they could do better: Since the last inspection the manager had been reviewing the care plans more frequently but still not monthly. One file had been reviewed on the 28/9/08, just after Care Homes for Older People Page 7 of 29 the last inspection, then on the 30/10/08, however a three month period past and it was not reviewed again until 30/01/09, and then 14/3/09. This service has a complaints policy on display and easily accessible to residents and visitors to the home, however records of investigations and responses to complainants are not always recorded on file. Since the last inspection all staff have attended further safeguarding training. The manager has also resourced a copy of local safeguarding protacols and incorporated this into his own policy. However the content and guidance in the policy need some clarification in places to ensure that information is not ambiguous, and staff have clear directions to follow in the reporting of safeguarding referrals. Checks show that record keeping is improving, however there are some gaps and omissions, and some entries are not always clear. Records indicated that the manager has started to carry out supervision with all staff every two or three months. At present this is only in the early stages, and this system needs time to establish a regular pattern to ensure that all staff are recieving six sessions each year. All records in this home are now being securely stored in a locked cabinet. They were in good order and risk assessments were in place to promote the safety of all the residents living in Holly House, however review processes could be improved. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home understands the importance of having enough information when choosing a care home. Pre admission documentation was in place, and was being used effectively for prospective admissions to the home, to ensure that their needs could be met efficiently in this home. Evidence: The statement of purpose and the Service Users Guide had been reviewed and updated and a copy given to each resident. The documents were also available for prospective residents and their families. We were not aware that these documents had been produced in any other format i.e. large print or braille. We encouraged the manager to display a copy of the inspection report so it was available for visitors. Each resident had a contract and a copy of the contract was held by the home. This Care Homes for Older People Page 10 of 29 Evidence: contained individual information including fees. During this inspection we viewed the pre admission assessment of the most recent admission to the home. The document was clearly dated and signed, so it was very clear when it had been completed, and by whom. This document contained detailed information relating to individuals specific needs, preferences and wishes, and was then used as a foundation for the care plans following admission. Residents are welcome to visit the home prior to making a decision about admission, however when this is not possible, families are encouraged to do so on their behalf. This home does not provide intermediate care. Care Homes for Older People Page 11 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with residents and their representatives. Medication records were accurate and in good order, contained the required entries and been signed appropriately by staff. An internal audit process was in place to support the system. Evidence: We looked at the care plans of three people using the service including the latest admission. Since the last inspection the manager had been reviewing the care plans more frequently but still not exactly monthly. One file had been reviewed on the 28/9/08, just after the last inspection, then on the 30/10/08, however a three month period past and it was not reviewed again until 30/01/09, and then 14/3/09. When care plans were reviewed the manager or a senior member of staff documented Care Homes for Older People Page 12 of 29 Evidence: the review so that all staff could easily see the progress or deterioration of a resident. The care plans were now written in more detail and explained why staff needed to do certain things. For example one care plan for personal care that we read explained how staff needed to provide the care and included, allow (residents name) to try to fasten buttons. This is important to maintain for purpose of self confidence. We believed this explained to staff why certain actions had to take place. The manager had introduce a system to audit care files to ensure that the required inormation was included and current. The files we sampled included a variety of differing assessments including nutritional, tissue viability and falls. These were completed at the same time as the care plans were reviewed but it was not always obvious how staff were to react to a change in score. As reported in the last report, it was apparent that people using the service were registered with local GPs and the home had a good relationship with community health professionals and could seek advice from them if they needed to. We saw an array of walking aids around the home, all being used appropriately. All of the residents that required it, had a moving and handling risk assessment in place, and all moving and handling practices that we observed were safe and appropriate. Interactions between staff and residents were observed to be respectful and dignified, and the staff that were on duty appeared very confident in their roles. We were however concerned that the visiting chiropodist was carrying out treatments in the communal lounge. We advised the manager this would be more appropriately carried out in an allocated area of the home, or the residents private rooms. During this inspection we looked at the Medication Administration Record (MAR) sheets for all sixteen residents living in this home at present. These documents were very neat and tidy, and had been accurately completed with staff signatures and omission codes where appropriate. Where doses of medication had been refused or not required, supporting reasons were clearly recorded on the reverse of the MAR sheets. We picked six residents MAR sheets at random, and reconcilled the stocks for each. This included medication prescribed on an as required basis, and medication that was not dispensed in the blister packs. These all reconcilled accurately. We observed the staff on duty dispensing the teatime medication. This was being done in a safe and competent manner. Two residents were prescribed Temazepam tablets at night. These were being appropriately stored in the Controlled Drugs (CD)s cabinet, and recorded in the CD register. The manager advised us that he has spoken to the pharmacy supplier and has a new CD cupboard on order. Care Homes for Older People Page 13 of 29 Evidence: Since the previous inspection in September 2008, all staff had attended further training on medication administration, the storage system has been improved so that all residents have an individual storage box in the trolley, and the manager and senior carers are auditing the MAR sheets and stocks at least twice weekly. This has improved the safety and accuracy of this system in this home. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home are encouraged to maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and people are supported to make individual choices within their daily lives. Evidence: When we arrived at the home for this inspection it was 14:00 hours, therefore we did not observe the midday meal, however at supper time we noted a wide variety of sundries being offered. These ranged from cheese on toast, sandwiches and soup, to those who only wanted to partake in tea and home made cakes. Menus were varied and offered alternatives for each meal. Storage cupboards were well organised and well stocked, and we noted that jars of produce were being dated when opened. A menu of sausage meat casserole with carrots, onions, swede and potato and mixed vegetables followed by jam and coconut sponge and custard, which was planned for the following day was already displayed on a board, and the manager showed us photographs that he has taken of plated meals in preparation for picture Care Homes for Older People Page 15 of 29 Evidence: menus. There was an activity programme on display. This incorporated a variety of leisure activities including; chair excersises, skittles, quizzes, manicures and picture recognition. Visitors from the local church also visit on a regular basis, and are involved in accompanying the residents on short outings in the village and local surrounding areas. On the day of the inspection interactions between staff and residents was relaxed, and residents were comfortably engaged in conversations and a singing session. Two residents told us that they prefer to spend time in their rooms, rather than join in the group activities. Visitors are welcome in the home at any time, and are encouraged to join in any planned celebrations. There was a poster on display inviting everyone to help celebrate the forthcoming 100th birthday of one resident. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This service has a complaints policy on display and easily accessible to residents and visitors to the home, however records of investigations and responses to complainants are not always recorded on file. Evidence: There is a complaints policy in place, which has been reviewed and clearly reflects all the necessary information. This is displayed on the noticeboard in the home, and each resident has a copy of this in a file with the Service User Guide and Statement of Purpose, which is in their bedroom. We viewed the complaints file, and two complaints had been recieved and duly recorded in a complaints book since the previous inspection. One had come via the Commission for Social Care Inspection (CSCI) and we had requested a response following the homes investigation into the matter. This response was not recieved within the timeframe specified in the policy, and we had to contact the manager to chase it up. There was also only limited detail filed as to how the investigation had been carried out, and the evidence to support the findings. The second complaint that had been recieved, had again been recorded clearly, however evidence to identify how any investigation had been carried out was not recorded, and there was no response letter on file. Care Homes for Older People Page 17 of 29 Evidence: Since the last inspection all staff have attended further safeguarding training. The manager has also resourced a copy of local safeguarding protacols and incorporated this into his own policy. However the content and guidance in the policy need some clarification in places to ensure that information is not ambiguous, and staff have clear directions to follow in the reporting of safeguarding referrals. When discussed with the manager, he demonstrated that his first point of call to report allegations of abuse would be the police, we reminded him that the local safeguarding team should be involved in the initial reporting process. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This home provides a clean, comfortable and safe environment for the residents who live here. Evidence: We undertook a tour of the building during this inspection. All areas were free from offensive odours and very clean. The home was tidy and free from clutter, and provided a comfortable and homely atmosphere. The kitchen, which had caused some concern at the last inspection, was very clean. It had been painted and old condemned equipment removed. Fridge and freezer temperatures were being monitored and recorded daily, and the broken freezer seen at the last inspection had been replaced. The dining room was set up for teatime with napkins and wine glasses providing a pleasant place to dine. Other areas of the dining room which we felt were rather disorganised previously, were tidy, and equipment that we felt was inappropriately stored in the dining room, such as specimen bottles and catheter bags, have now been removed from this area of the home. We visited the bedrooms of several individuals in the home. All were clean and tidy, Care Homes for Older People Page 19 of 29 Evidence: and were decorated and furnished accounting for personal taste. Personal photographs and ornaments brightened the rooms, giving each its own personal touch, and reflecting the residents life history. The manager advised us that there is an ongoing decorating programme in place whereby as rooms become vacant in the home they are redecorated. The maintenance book indicated that any maintenance issues are addressed as and when they occur, however there in no evidence proactive approach for planned maintenance and redecoration. Bathing facilities were clean and tidy, and bath lifts and hoists had been serviced appropriately. Unused furniture, such as mattresses and mobility aids, that were previously being stored in an unused bathroom have now been removed. The gardens at this home are very well tendered and provide an inviting area for the residents to enjoy the fresh air, weather permitting. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This service recognises the importance of training and delivers a programme that meets the National Minimum Standards. Recruitment procedures are fully adhered to so that residents are protected. Evidence: There are presently only sixteen residents living in this home. Staffing numbers have been adjusted accordingly and at present the staffing levels are; three staff on the morning shift, two staff on the afternoon shift, and one sleep in and one waking carer at night. The manager and the duty rotas confirmed these numbers, which did not include the manager. We advised the manager that these numbers should be increased, if there is any increase in resident numbers and needs. The staff team in this home is only small, with ten people in all, to cover the day and night shifts. The manager told us that all staf were expected to work day and night shifts to ensure continuity of care, and many of the staff also had more than one role within the home. For example, the cook also worked as an activity co-ordinator, and a manitenance person was also employed as a carer. We were however confident that all the staff who had dual roles had the necessary training and qualifications for the various roles. However we were a little concerned that rotas were not yet completed for the following week, therefore staff could not plan their rest time as they were unaware of the shifts Care Homes for Older People Page 21 of 29 Evidence: they would be required to work the following week. We looked at the files of two members of staff, including one that had been recruited since our last visit. Both files contained, fully completed application forms, appropriate references, Enhanced Criminal Record Bureau (CRB) checks, various forms of identification including passports, birth certificates and home office documentation where appropriate. Job descriptions and contracts of employment were present and correctly signed and dated. We also noted that there was a form that had been completed by a resident in one of the files, indicating that they had been involved in the interviewing process and appointment of this person. This is an excellent practice to adopt. The files that we looked at both contained various training certificates, and a training matrix, that we looked at, identified that all staff have attended training in safeguarding, moving and handling and medication administration since the last inspection. All staff with the exception of one have acheived NVQ level 3 in care, and individual members of the team are being nominated to attend train the trainer courses in various subjects. We looked at the training programme for the forthcoming year, which included subjects such as; Tissue Viability, Person Centred Care, Mental Capacity, Care Planning, Diabetes and Managing Challenging Behaviour, as well as the mandatory courses which everyone must attend. This is a very encouraging improvement since the last inspection of this home. Many of the staff in this home are from overseas and are also attending english lessons that have been arranged by, and are held in the home. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is aware of the need to keep up to date with practices and continuously develope his own skills. Checks show that record keeping is improving, however there are some gaps and omissions, and some entries are not always clear. Evidence: The manager of this home is also the owner and has owned this home for seven years. He advised us that since the previous inspection he has been spending more time in the home, reviewing and introducing new systems so that different areas of the home can be managed more closely. Records indicated that the manager has started to carry out supervision with all staff every two or three months. At present this is only in the early stages, and this system needs time to establish a regular pattern to ensure that all staff are recieving six sessions each year. Care Homes for Older People Page 23 of 29 Evidence: The staff that we observed and spoke to during this visit, were knowledgeable about the individuals they care for and the procedures they must follow. Communication between staff is promoted in this home through handover meetings and a communication book, so that staff are always made aware of any specific changes to individuals care. This home does not hold any personal money for the residents in this home. All bills are invoiced monthly to the next of kin, therefore the staff are not involved in any monetary transactions within this home. All records in this home are now being securely stored in a locked cabinet. They were in good order and risk assessments were in place to promote the safety of all the residents living in Holly House, however review processes could be improved. Regulation 37 notifications had been recieved by CSCI since the last inspection, relating to deaths in the home, however there was some confusion regarding the reporting processes of accidents and other incidents. We were unable to ascertain how these incidents were recorded, except within the communication book, and the manager explained that he was going to introduce an accident log. There was however one incident record that we found, relating to an unwitnessed hand injury, which required a medical opinion for swelling and bruising. We had not recieved a regulation 37 notification regarding this matter. We reminded the manager that these notifications must be sent to CSCI, in order for us to monitor trends on incidents in the home. Serious consideration must also be given as to whether a safeguarding referral is required in these sort of circumstances. Quality assurance is addressed by surveys being completed by the residents and their families, however at present other professionals such as visiting district nurses and GPs that work with the home, have not yet been approached with this system. This is planned for the near future. We look forward to seeing the results from this process. The manager and the maintenance man are responsible for health and safety checks including water temperatures and fire checks. These are all carried out regularly and recorded. It was clearly recorded when a problem had been identified, and what action had taken to rectify the problem. The home had a contingency plan for any major emergency and would use the nearby church premesis. Staff regularly discuss how they would evacuate the home in the event of a fire. Care Homes for Older People Page 24 of 29 Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 17 The registered manager must ensure that all information related to the investigation and response to complaints are clearly recorded and held on file for inspection. People who live in this home must be protected by the complaints procedure. 30/06/2009 2 33 24 The manager shall prepare 30/06/2009 and supply to the Commission for Social Care Inspection, a report in respect of the quality of care in the home whicn msut be kept under review. People who live in this home must be protected by regular quality care reviews. 3 36 18 The manager must ensure that all staff recieve six formal supervision sessions each year. 30/06/2009 Care Homes for Older People Page 27 of 29 The staff in this home must be appropriately supervised. 4 38 37 The registered manager must ensure that all reportable incidents are submitted to the Commission for Social Care Inspection, withing the time frames specified in the National Minimum Standards. People living in this home are protected by reporting processes in this home being followed appropriately. 25/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The home should consider producing the information documents in formats more suitable for some of the more disabled residents. The home should consider reviewing their audit processes for monitoring care plan up dates, to ensure there are no omissions and all are appropriately up dated to reflect individuals changing needs. The home should consider further review and more clarification of reporting processes in their safeguarding policy. The manager should consider preparing staff rotas in advance so that staff have a fair opportunity to arrange their rest time effectively. The home should consider keeping a copy of the most recent CSCI report on display within the home. 2 7 3 18 4 27 5 37 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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