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Inspection on 30/08/07 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 30th August 2007.

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.

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

What has improved since the last inspection?

The Registered Manager has obtained a lockable facility for locking away the personal information of residents, and the number of controlled drugs were checked and found to be correct.

What the care home could do better:

Residents needs would be more effectively covered by ensuring that: Management systems need to be improved to ensure residents welfare needs are protected by ensuring that there are comprehensive and up to date Care Plans in place, there is appropriate referral to medical authorities and the Commission for Social Care Inspection for accidents needing treatment, that medication systems are complete and unused medication is quickly returned, that facilities are upgraded, that all staff have all received appropriate training in all relevant care issues, that all statutory checks are in place before staff commence employment, that there is always full health and safety in place regarding proper Risk Assessments in place, fire safety and protection from hot radiators, and that residents privacy and dignity is respected by ensuring that all toilet doors have proper locks fitted.

CARE HOMES FOR OLDER PEOPLE Holly House (Milton Malsor) 36 Green Street Milton Malsor Northampton Northamptonshire NN7 3AT Lead Inspector Keith Charlton Unannounced Inspection 30th August 2007 10:35 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 (Milton Malsor) DS0000043334.V347038.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 (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly House (Milton Malsor) Address 36 Green Street Milton Malsor Northampton Northamptonshire NN7 3AT 01604 859 188 01923 840278 info@hollyhouseresidential.co.uk 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) Mr Parvin Kumar Menon Mrs Madhu Menon Mr Parvin Kumar Menon Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 25th January 2007 2. Date of last inspection Brief Description of the Service: 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. The weekly fees are £338 to £480 per week. The Registered Manager provided this information on the day of the inspection. There are additional costs, e.g. for hairdressing, dry cleaning, telephone calls etc, which are detailed in the service user guide. A service users guide to the services the home offers is supplied to applicants and the last Inspection Report is available on request. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included checking on the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report, which had Requirements due to have been acted upon by the time of this inspection. There has been three complaints made about the service since the last inspection regarding a number of issues – providing proper personal care, insufficient food, deposits left by a prospective resident and not returned, the attitude of the Registered Manager, not providing accommodation to a resident with challenging behaviour, unclean clothing, residents not wearing their own clothes, residents having to go to bed early, call bells being switched off, and a resident being prevented from leaving to another home with the next of kin. These issues have been investigated by the Registered Provider and found to be: not upheld, though the Commission for Social Care Inspection did advise the Registered Providers that they needed to allow a resident to leave with her relative. The Inspection took place between 10.35 and 16.00 on day one, and between 10.00 and 14.15 on day two. The inspection included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with nine residents (though this was limited in some instances owing to the difficulty with communicating with residents with a level of mental frailty), three members of staff, a relative and the Registered Providers. What the service does well: There were a number of issues which covered residents needs – residents and the relative spoken to were very satisfied with the care they received from staff and management and they liked the food, the activities provided and their Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 6 bedrooms and did not think there were any unnecessary rules, staff were found to be friendly and helpful in their dealings with residents and residents. The home was clean and tidy throughout. What has improved since the last inspection? 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. The summary of this inspection report can Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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 is managed and detailed to meet the needs of residents. EVIDENCE: Assessments were examined and confirmed residents were admitted on the basis of an assessment of their needs. Residents confirmed that preadmission visits are arranged and written information about the home’s services is provided by the supply of the Service User Guide. The service does not offer intermediate care. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify care needs but do not always proscribe action to residents to ensure needs are fully met. Residents health needs are not always met. Medication systems are not sufficiently robust. EVIDENCE: Care plans inspected were found to contain relevant information regarding residents needs. However no resident was aware of the existence of a Care Plan though the Registered Manager showed that one relative had signed a plan. The Registered Manager needs to inform all residents/ relatives that they can be involved in setting up the Care Plan. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 11 However some areas of need are not specific enough – e.g. a residents with challenging behaviour had no plan in place as to how to deal with this, a resident with a head wound had no information as to whether medical authorities had been contacted as how to deal with the injury, there was no evidence of the last appointments regarding medical checks for the optician, dentist and chiropodist, and a record did not specify what mobility aids were in place. The Registered Manager said that he would update the plans as soon as possible. The Registered Manager has subsequently stated that records of medical checks were kept elsewhere but the proper procedure was followed. There is a personal history section to ensure residents are seen as individuals with a valued past but this was only completed for one of the three records seen. The Registered Manager said he was awaiting information from relatives regarding this, although one of the resident’s was alert and able to supply this information herself. There was no evidence that staff had been asked to read Care Plans by the Registered Manager. The Registered Manager said he would remind staff to do so and ask them to record they had done so. Monthly reviews of plans had not been fully carried out on all sections of the Plan to ensure it was still relevant to residents needs. The inspector looked at issues raised in previous complaints and found that residents said that they were assisted to wash, clothes were clean, they could choose when they got up and went to bed, food portion sizes were good and residents were assisted to eat when necessary and that their weight and fluid intake was monitored. Residents said their call bells worked. The inspector checked and this was found to be the case. There were however a number of comments regarding the need for more staff at certain times as residents said they had to wait for up to thirty minutes for attention and were left on the commode for long periods which can cause discomfort and is a health and safety risk - see the staffing section for further discussion regarding this. The Registered Manager has subsequently stated that this long wait on the commode did not take place and it was on the resident’s request of being left on the commode. If this is the case it needs to be recorded as agreed with the resident on the Care Plan. Accident records were viewed. A resident was found to have a head injury on 14/8/07 but there had been no referral to medical authorities. The Registered Manager said this would be checked and followed up immediately. There was another incident of a head injury on 19/6/07, which was also not referred to Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 12 medical authorities. The Registered Manager has subsequently stated that these records were kept elsewhere but the proper procedure was followed. It is recommended that a medical alert procedure be drawn up for staff to alert them to the proper steps to follow regarding injury to residents. Some accident reports just recorded the incident without stating the assessment of the resident and what action was taken if any. The Registered Manager said he would speak to staff regarding report writing. It is also noted that the Registered Manager has not reported such incidents to the Commission for Social Care Inspection under the Regulation 37 procedure so they can be properly monitored as no incidents have been reported since December 2006. This needs to be followed. The inspector observed that a resident was transferred in a wheelchair when there was no footplates attached, which is a health and safety issue as it could cause injury, though footplates were found on the floor in corridors. The Registered Manager said this would be followed up with staff. Medicine records were in generally up to date. However there was one medication not signed for the day before, a staff member had only signed with one initial which does not assist with a proper audit trial and a forticip food supplement had not been signed in and recorded as given. The inspector observed that there was unreturned medication from 2006, though medication returns records were in place, which further queries why there was unreturned medication. Medication was viewed to be in an unsecured fridge despite this being stated as required to be rectified in the pharmacist’s report of 26/2/07. Staff members said they had in house training on medication. The Registered Manager stated that a recognised approved trainer also trains staff. The inspector observed that medication is issued to residents from a recognised blister pack system. Controlled drug records were checked and found to be properly kept. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to exercise choices in their lifestyles, though this needs to be reviewed for food. EVIDENCE: Residents said that there were activities most days and that they were satisfied with them. A staff member showed the inspector an up to date Activities Programme, which recorded daily activities. The inspector observed that activities were held in the afternoon - bingo and a quiz. Residents expressed no further preferences regarding activities apart from looking at DVDs and having some more trips out. The Registered Manager said that a DVD player had been purchased and this would be installed and used. . Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 14 Residents Meetings are not organised on a regular basis though the Registered Provider said that after lunchtime residents are spoken with regarding issues of interest, though these are not recorded. The inspector recommended that residents/relatives meetings be set up and recorded to inform management as to suggestions/quality of life issues for residents. It is recommended that memory boxes, containing valued items, be set up for residents, particularly for residents with dementia, so as to provide valuable reminiscence material for residents with dementia. Residents confirmed that visitors were made welcome by staff and relatives could take residents out. This was also confirmed by a relative who was very satisfied with the standard of care given to her relative. Residents and staff indicated that there were no rules in general and there was free choice regarding getting up and going to bed times. Residents can have alcohol in their rooms if they choose. All residents said they enjoyed the homemade food. There is not a choice of food though residents said if they wanted an alternative this would be supplied. It is recommended that the Registered Provider offer a choice of two meals each day, as per the National Minimum Standard. A resident’s Care Plan indicated a greater range of food was desired rather than that indicated on the menu. It was also recommended that a menu board be displayed to supply information to residents. The Registered Manager said these issues would be followed up. Food records were in place. A resident was seen to be receiving assistance from staff to eat his food. The food tasted was found to be of a good standard with flavour. There was a good range of fresh vegetables and the cook said she often offers stewed fruit, which helps residents to have a wholesome diet. There was a choice of dessert. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current systems do not fully protect residents from the possibility of abuse. The complaints process needs to be more robust to ensure residents are always protected. EVIDENCE: Residents said that they did not need to complain but if they thought the Registered Manager would look into it properly if they ever needed to. The Complaints book was viewed where there were no complaints recorded since the last inspection. However the Commission for Social Care Inspection has received three complaints about the service regarding issues already stated. These were sent to the Registered Provider for investigation though not found to have been upheld. They need to be entered in the complaints book. The Registered Manager also needs to ensure that the Commission for Social Care Inspection is informed as to the outcome within the timescales laid down, as reminder letters had to be sent to the Manager to seek the outcome of the complaints. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 16 There is a Complaints Procedure displayed on the notice board, which did not fully comply with the National Minimum Standard as it did not give a choice of going to the agency dealing with complaints first rather than the home. It now needs to state the local Social Service Department is now the lead agency for complaints. The Registered Manager said this would be changed. Staff members were asked about their understanding of the adult protection procedures, and demonstrated a generally good understanding of them though one was uncertain as to how to contact the Commission for Social Care Inspection. The Registered Manager said staff would be reminded as to this issue. It was found that a staff member had commenced employment without statutory employment checks being carried out – the Protection of Vulnerable Adults check and references were also dated as being received as being received after the commencement date. An Immediate Requirements Notice was issued to remind the Registered Providers that this was not an acceptable practice, as it could mean the employment of unsuitable staff. The other staff records seen were satisfactory except for the absence of an employment history so gaps in employment could be explored. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is kept clean though some aspects of facilities are beginning to show signs of wear. EVIDENCE: All residents said they were satisfied with their bedrooms. The inspector viewed residents bedrooms, which were homely, and contained residents possessions – pictures, photos, ornaments, TV, radio etc. The main lounge was clean and furnished with homely fittings though furniture in the lounge and dining room was beginning to show signs of wear. The dining Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 18 room carpet was also worn. The Registered Manager said he had already identified these issues and they would be replaced in the next year. It was recommended that the home should be signed to assist residents with dementia, e.g. calendar and clock to be displayed, relevant pictorial signs identifying different rooms etc. A small lounge is available for reading and for visitors. Bathroom door lock fittings to two bathrooms need to be installed to preserve residents privacy and dignity. The Registered Manager said some parts of the home had dim lighting, and action is being taken as needed. Corridors are due to be repainted as some areas had flaking paintwork. There are no radiator covers to prevent scalding to most radiators. The Registered Providers said that they would be fitted on all radiators in the coming weeks. All parts of the home were clean and tidy. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels may not meet all residents needs. Recruitment processes need to be thorough to ensure the protection of residents from unsuitable staff. A staff training system needs to be fully in place to ensure staff are fully aware of all of residents needs. EVIDENCE: There were a number of comments received by the inspector that there were not enough staff on duty as they had to wait a long time for attention. The staffing rota showed that at times there were only two care staff on duty to cover up to twenty two residents. As there are a number of residents who need the attention of two staff at times to assist with their personal care and that a large number of residents have dementia, the Commission for Social Care Inspection would expect that there is a minimum of three care staff on for all daytime and evening periods. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 20 There is one domestic staff member on five days per week. Domestic cover needs to be seven days a week as at weekends this puts more pressure on the two care staff to cover these duties. The Registered Manager needs to ensure that there is always sufficient staff on duty to cover residents needs. There is one awake staff on duty at night with another staff member sleeping in. Staff recruitment files did not confirm that proper recruitment procedures have been followed as one file were sampled and all did not contain required information – this has been referred to earlier in the Report. Evidence of training programmes for staff was present though only up until October 2006. There was no evidence that new staff were undertaking the Skills for Care induction programmes though the Registered Manager said he had recently obtained the relevant manual and would be using this in the future. The Registered Manager said that one staff had a National Vocational Qualification level 2 and another staff was currently undertaking this with another staff commencing level 3 in October 2007. The Registered Manager thought that two other staff had the equivalent to National Vocational Qualification level 3 as they had overseas nursing qualifications. This needs to be confirmed in writing from the relevant body, as there is no evidence of such equivalence. This is important so that the home meets the National Minimum Standard of a minimum ratio of 50 trained care staff having National Vocational Qualification level 2. However as regards other essential training, staff files contained some evidence of training though and not all staff had received training on a range of essential care issues – e.g. food hygiene, health and safety, fire, first aid, moving and handling, infection control, dementia, challenging behaviour, residents health conditions – stroke, diabetes, hearing and sight impairment etc, which is necessary for staff to have a better understanding of these conditions and so be better able to assist residents. The Registered Manager said that he trained staff in Moving and Handling practice. However he is not an accredited assessor so trained person should carry this out instead. The Registered Manager was recommended to draw up a training matrix to indicate which staff needed training in what topic so this can be easily checked and planned. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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. Systems are not fully in place to protect the health and safety of residents, and need to be tightened to provide full protection. EVIDENCE: From comments received from residents and staff there was satisfaction with the performance of the management in carrying out their duties. There was no evidence that staff are now offered regular formal supervision. It is recommended that this is carried out every two months, as per the National Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 22 Minimum Standard, to ensure consistent staff practice and support, identification of training needs, discussions on issues they wish to raise etc. The Registered Manager said that no residents monies are held by the Registered Providers, as all financial dealings are through relatives. The Registered Manager said that there are Risk Assessments for safe working practices though they were not present in the home. There was a new manual obtained that the inspector saw and the Registered Manager said he would be completing in the near future. There was evidence that the Quality Assurance system was being carried out this year, though there has been a gap, as this was not carried out in 2006, to check the service for residents. The Registered Manager said this would also be carried out for other interested parties - relatives, District Nurses, GPs, Social Workers etc, and an Action Plan to be drawn up and included in the Statement of Purpose. Staff meetings are not held frequently as the last one was in April 2007. It was recommended this is carried out more regularly – the National Minimum Standard is every two months. Fire Precautions: fire training has been carried out on a regular basis, though it was recommended that proper unannounced fire drills are carried out instead. Staff were not fully aware of the fire procedure. The Registered Manager said this would be followed up. Emergency lighting testing is carried out on a monthly basis and fire bell testing is carried out on the required weekly basis. There was a fire risk assessment for the home, to ensure that fire issues have been considered and residents fully protected from fire. Fire doors to the kitchen was found to be wedged open on the first inspection day though this was then rectified by the Registered Manager attending to the approved closure device. Fire doors must not be wedged open so as to ensure proper fire safety. There was a broken fire door panel to a corridor ceiling. The Registered Manager said this would be quickly repaired. A hot water outlet in a first floor bathroom was found to be 41c, close to the National Minimum Standard of 43c, which was satisfactory. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 1 Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 24 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 7 Requirement Resident’s health and personal care needs and choices must be protected and followed and evidenced in their plan of care. The Registered Person must ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. To this end – residents need medical assistance to be summoned when necessary and that this is evidenced. Medication must be kept securely, supplied as prescribed recorded properly and all old medication must be returned as soon as possible. Residents must be safeguarded from abuse by staff checks being in place before employment commences and staff must know how to operate the full Protection of Vulnerable Adults procedure. Timescale for action 31/10/07 2. OP8 12 31/08/07 3. OP9 13 31/08/07 4. OP18 13 31/08/07 Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 25 5. OP27 18 Staffing must be such to ensure 31/10/07 the needs of residents are met at all times. Statutory staff checks must be in place before staff commence employment. A staff training programme must be implemented to provide all relevant training to staff. Health and Safety Risk Assessments must ensure that all identified risks are controlled, e.g. that Risk Assessment is carried out for all potential hazards and that fire safety is fully protected. 31/08/07 6. OP29 19 7. OP30 18 31/12/07 8. OP38 13 31/10/07 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 OP36 Good Practice Recommendations The Registered Person need to evidence that staff are appropriately supervised and that this is recorded to include all aspects of practice, philosophy of care in the home and career development needs. Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Holly House (Milton Malsor) DS0000043334.V347038.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!