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Inspection on 02/06/05 for Hollymount Nursing & Residential Care Home

Also see our care home review for Hollymount Nursing & Residential Care Home for more information

This inspection was carried out on 2nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Hollymount provided residents with a safe, comfortable and homely place to live. Residents were able to bring in some pieces of furniture, ornaments and other personal items. Several commented on how much they liked their bedrooms. One resident said, "My room`s lovely, always fresh, clean and warm." The home was well equipped to assist residents who had problems with their mobility. There were handrails around the corridors and grab rails and other equipment in the bathrooms. One resident commented that the special chair in the bath helped her to be independent. Residents, staff and visitors said the home was organised and well managed. Residents were very complimentary about the manager and staff. When speaking about the manager, one resident said "Amanda`s very good, she always has time for us." Another resident said, "the staff are excellent, I was dreading having to come into a home but it`s very good and very well managed." There was open visiting at the home and residents were happy with the arrangements. Two relatives said they were able to visit at any time and were made to feel welcome. One resident, whose family visited late in the evening, said that staff always let them come in, even if she was in bed.

What has improved since the last inspection?

The programme of activities had improved since the last inspection. One resident commented, "there`s lots more going on now, it`s much better." There was something available every day and residents were able to make suggestions for new activities during their monthly meetings. The way that staff were recruited to work at the home was better. The manager made sure that only staff who had been through the proper checks were able to start working with the residents. The manager had started to have regular one-to-one meetings with each member of staff. This gave them opportunities to talk about their work with residents and to look at any areas where they might need extra guidance or training.

What the care home could do better:

Residents who funded their care privately should be provided with a written contract outlining the terms and conditions of their residency. Some of the residents` care records were not complete and missed out some important information. Others had not been brought up to date and did not correspond with the care that was being given. There must be an improvement in this area to ensure that staff always have proper written records to refer to. The induction training for new staff did not cover all of the recommended issues. Not all staff had received updated training in health and safety topics and there were not enough staff with a first aid qualification. The level of staff training, particularly in the area of health and safety must be improved, in order to protect residents and staff.

CARE HOMES FOR OLDER PEOPLE Hollymount Nursing & Residential Care Home 3 West Park Road Blackburn Lancashire BB2 6DE Lead Inspector Jane Craig Unannounced 02 June 2005 09:00 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 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. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hollymount Nursing & Residential Care Home Address 3 West Park road Blackburn Lancashire BB2 6DE 01254 266450 01254 266451 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Longfield Care Homes Limited Mrs Amanda Jane Walsh Care Home with Nursing 38 38 Category(ies) of Physical disability (PD) 25 registration, with number of places Old age, not falling within any other category (OP) 38 Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Within the overall total of 38, a max of 24 service users requiring nursing care who fall into the category of either OP or PD 2 Within the overall total of 38, a max of 28 service users requiring personal care who fall into the category of OP 3 Within the overall total of 38, a max of 1 service user requiring personal care who falls into the category of PD 4 The Registered Provider must, at all times, employ a suitabily qualified and experienced manger, who is registered with the National Care standards Commission. Date of last inspection 13 January 2005 Brief Description of the Service: Hollymount Nursing and Residential Home provides care for up to 38 people who have personal care or nursing care needs. The home is located in a residential area close to Corporation Park and approximately half a mile from Blackburn town centre. The main road with shops and other amenities is within walking distance. Hollymount is an extended detached property. It offers mainly single room accommodation with some en-suite facilities. Ample bathrooms and toilets are located close to bedrooms and communal areas. There are three lounges and a dining area. Decor and furnishings are of a good standard; comfortable and homely. Residents have access to well maintained gardens and a patio area. There are car parking spaces to the front and side of the home. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of 2005 and took place over 8 hours. There were 27 residents accommodated in the home. The inspector met most of the residents. 8 residents made comments about their experiences of living in the home, some of which are included in this report. Discussions took place with the registered manager, five members of staff, two visitors and a visiting professional. A tour of the premises took place and a number of documents and records were viewed. What the service does well: What has improved since the last inspection? Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 6 The programme of activities had improved since the last inspection. One resident commented, “there’s lots more going on now, it’s much better.” There was something available every day and residents were able to make suggestions for new activities during their monthly meetings. The way that staff were recruited to work at the home was better. The manager made sure that only staff who had been through the proper checks were able to start working with the residents. The manager had started to have regular one-to-one meetings with each member of staff. This gave them opportunities to talk about their work with residents and to look at any areas where they might need extra guidance or training. 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. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Not all residents had any written information about their terms and conditions of residency. There was a lack of comprehensive assessment records for some residents. This may result in essential information not being passed on and residents’ needs not being identified and met. EVIDENCE: Administration files were seen for 4 residents. 2 contained individual service agreements with social services. The others did not include a contract or terms and conditions of residency. One visitor said that she had not been given a contract to sign on behalf of a relative, who was self-funding. Care management or hospital discharge assessments were on some of the residents’ care files but the manager stated that these were not always available until after the resident moved into the home. The registered manager had also assessed some of the newer residents prior to confirming a place at the home. The assessment tool used followed the activities of living model. The manager had conducted a full assessment and was knowledgeable about the resident’s needs but the information recorded was scanty. Some of Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 9 the assessments seen did not provide enough detail for other staff to properly identify needs and draw up an initial care plan. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 There were some examples of good practice and residents’ were satisfied with the care they received. However, care records were not always accurate which could result in residents’ needs being overlooked. Care was provided in such a way as to promote residents’ privacy, dignity and independence. Robust medicines management policies and procedures were in place, however all staff must adhere to these in order to protect residents. EVIDENCE: The care records for 4 residents were examined and several others were viewed in less detail. Most of the care plans contained very clear directions for staff to follow to meet residents’ personal and healthcare needs. However, these were not always followed. For example two plans contained instructions for staff to monitor blood glucose levels weekly. Records showed that one was monitored every two weeks and the other less frequently. Wound progress and treatment charts were not kept up to date. Care records for one newly admitted resident were not complete. Their care plans did not correspond with their needs as highlighted on their pre-admission assessment. On speaking with the resident and the manager it was apparent that some important information had not been recorded, although the resident said that she was being very well looked after. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 11 Most plans contained relevant risk assessments for moving and handling, falls, nutrition and pressure sore risk. Pressure sore prevention measures were recorded. At least one resident had cot sides on their bed but there was no risk assessment to support this. Risk assessments and care plans were generally reviewed every month but were not always updated; therefore there were conflicting directions on some plans. None of the residents spoken with wanted to be involved in drawing up or reviewing care plans. One said “I can’t be bothered with that.” Evidence was seen on files that relatives were invited to participate in care reviews. Despite the lack of recording in some areas, staff spoken with were knowledgeable about residents’ personal and health care needs. Residents felt their needs were met. Several residents praised the staff and said that the care was very good. One said, “they always seem to know what to do.” One visitor said that the staff were wonderful and her husband had “everything he needs.” A visiting professional confirmed that the care was good and that referrals to other agencies were timely and appropriate. It was noted at the time of the inspection that residents were able to request visits from their GP. The standard of medicines management within the home was generally high. Documentation was clear and accurate and residents wishing to self-medicate were enabled to do so. However, at the time of inspection a member of staff was potting up medicines in advance of administration. This practice is contrary to the homes policies and guidelines issued by both the Nursing & Midwifery Council and Royal Pharmaceutical Society of Great Britain and places residents at risk. It was noted that the manager stopped this practice immediately and dealt with the situation appropriately. Residents said their privacy was respected and gave examples of staff always knocking on their door before entering and ensuring that they were kept covered as much as possible when they were receiving personal care. One resident talked about how staff preserved their dignity and independence and said “I like to be independent but I know they watch out for me.” Staff were taught about privacy and dignity during their induction training. One member of staff said that it was important to make sure that residents were appropriately dressed and groomed. One of the care plans directed staff to ensure that the resident’s clothing was changed if it was marked or stained after mealtimes. During the course of the inspection staff were seen to offer personal care in a discreet and sensitive way. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Residents were able to make decisions about their daily routines. They had opportunities to engage in social activities. Residents and their relatives were satisfied with the open visiting arrangements. EVIDENCE: Residents spoken to said that the daily routines in the home were flexible and they could choose when to get up and go to bed and how to spend their day. One said “I like to stay in my room for all my meals and the staff are very good about that.” When asked whether the home lived up to expectations, one resident said “the staff are excellent, I was dreading having to come into a home but it’s very good and very well managed.” There had been a significant improvement in the level and variety of activities offered in the home. There was a planned activity every day, which was advertised on the notice board. Residents were involved in planning new activities and the notes of the last residents meeting stated that they all enjoyed the current programme of entertainment. One resident said “there’s lots more going on now, it’s much better.” There was an open visiting policy at the home. One visitor confirmed that they were able to call in at any time and another said they were always made to feel welcome. One resident explained that her family worked until late but the staff didn’t mind them visiting when she was in bed. Another resident said she Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 13 was happy that her dog was allowed to visit. The home had links with the local community and had regular visits from the mobile library for books and videos. Local papers were delivered daily and distributed to residents. Children from the local nursery and others from the high school visited for celebratory events. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints information was good and residents felt any complaints would be listened to and acted upon. Permanent members of staff were clear about adult protection issues but this must be communicated to temporary staff in order to protect residents from abuse. EVIDENCE: A clear complaints procedure was displayed on the main notice board and included in the service users guide. Residents and relatives said they would go to the manager if they had any complaints. One resident said “ I go to Amanda (manager) if there’s anything wrong and she sorts it out.” There had been no complaints to the home or the Commission since the last inspection. The abuse policy dovetailed with the Blackburn with Darwen Protection of Vulnerable Adults Procedure, which was available for reference. Protection issues were also included in the induction training programme for permanent staff. The care staff spoken with had a clear understanding of adult abuse and their responsibilities for reporting, including whistle blowing. Training was also provided on restraint and missing persons. However, protection of vulnerable adults was not included on the induction programme for bank nurses and two spoken with were unclear about their role in investigating any allegations. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,24 and 26 The home was clean and well maintained. There was a good standard of décor and furnishings, providing residents with a safe, comfortable and homely place to live. EVIDENCE: On the day of the inspection the home was clean and tidy and free from offensive odours. There was a good standard of décor and furnishings throughout the home. Communal areas were homely and comfortable. The manager stated that there was an ongoing programme of redecoration and refurbishment. One resident said “we’ve had all new chairs and it’s very nice in here now.” Other residents talked about the home being clean, comfortable and a nice place to live. The home and grounds were well maintained and systems were in place to ensure repairs were carried out in a timely fashion. The home had been assessed by an occupational therapist with regard to adaptations and equipment and their recommendations had been actioned. Individual residents talked about equipment that helped them. One said, “the Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 16 bath chair helps me to be independent” and another said “I have my (powered) wheelchair so I can get about.” All of the residents spoken with were happy with their bedrooms. One said “my room’s lovely, always fresh, clean and warm.” A tour of the premises evidenced that many of the bedrooms had been redecorated and old furniture had been replaced. Some bedrooms were personalised to high degree and everyone had an option to bring in their own belongings. The manager stated that residents were asked on admission whether they wanted a door lock and again during care reviews. Residents said the laundry service was good. One said “our clothes get sent down at night and you get them back usually the next day.” Another said they didn’t know of anything getting lost. The laundry was organised and well equipped. As highlighted during previous inspections, the floor was partially carpeted. This has implications for infection control, especially as the carpet area was dirty and stained on the day of the inspection. Staff received awareness training in hygiene and infection control during their induction but this was not updated. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 There were sufficient numbers of staff on duty to meet the needs of the residents. Recruitment practices had improved. Pre-employment checks were carried out, providing safeguards for residents. The current level of staff training in some areas was not sufficient, which may place residents at risk of harm or result in their needs not being met. EVIDENCE: The staffing levels for the home complied with those agreed by the previous registering authority. There was evidence of flexibility and extra staff had been rostered in the evening to meet the needs and dependencies of the residents. Staff, residents and visitors said that they thought there were enough staff and the manager stated that she felt the home was safe with the staffing numbers and current clientele. One resident said “there are enough staff, there’s always someone around if you need them.” Another said, “there are enough staff, no-one gets neglected.” There had been improvements in the recruiting practices of the home. POVAFirst or CRB disclosures were obtained before staff commenced work at the home. Appropriate references were obtained and the application form had been amended to provide full information about the applicant’s previous employment. Not all staff files contained evidence of training and qualifications as stated on application forms and the manager should seek advice about work permits for 2 nurses who worked part time on the bank. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 18 Permanent staff received an induction training programme but as noted during previous inspections, this did not include all the relevant topics. The programme was under development at the time of the inspection and the manager was working towards meeting the National Training Organisation standards. A short induction programme was in place for trained nurses working part time on the bank. One nurse said it was excellent and covered fire safety, medication procedures and other policies and practices specific to the home. One nurse had not been provided with an induction from the manager and was unclear about the fire procedures and medication practices (see standard 9). Not all staff had received updated training in safe working practice topics and training in other areas was limited. There were almost 50 of care staff qualified to NVQ level 2 or above and other new starters were being enrolled on the course. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36 and 38 Residents had confidence in the way the home was managed on a day-to-day basis. The level of staff supervision provided safeguards for residents. The lack of refresher training for staff with regard to health and safety issues could potentially place residents and staff at risk of harm. EVIDENCE: Residents, visitors and staff were very complimentary about the way the home was managed on a day to day basis. One resident said “Amanda’s very good, she always has time for us,” another said “it’s more organised when Amanda’s here.” Staff felt that the registered manager was approachable, supportive and organised. One said “she’s on top of everything.” A visiting professional also said that they had a good working relationship with the manager. During the course of the inspection the manager demonstrated a clear understanding of her role and responsibilities and is working towards the development of the Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 20 service. The manager should enrol on the level 4 NVQ in management as planned. All residents’ finances were managed by their families, with only a few residents handling their own personal allowance. Clear records were kept of any monies handed over to the home for safekeeping, or money spent on behalf of residents. Informal supervision was provided by the manager who worked alongside staff on a day to day basis. One resident also commented that the long standing care staff kept up the standards by working with the newer staff. The programme of formal staff supervision was progressing. All existing staff had received at least one session since the last inspection and records showed the content was appropriate. The manager and staff said they found the sessions beneficial. The health and safety policy for the home was on display and clearly set out the responsibilities of the company and the employees. Not all health and safety training was up to date, (see standard 30) and there were not enough staff qualified in first aid. The manager was knowledgeable about health and safety legislation. Testing of fire safety equipment was up to date and all staff had been involved in fire drills. The manager stated that training in fire prevention was included within the drills and she was confident that the training was robust enough to ensure the protection of residents and staff. Evidence was seen of servicing and maintenance of gas appliances and electrical systems. Not all portable electrical appliances had been tested. Records of those which had were inadequate. Potentially hazardous items stored in bedrooms at the previous inspection had been removed and were stored securely. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 4 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x 3 3 x 2 Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15(1) Requirement Care plans must correspond with assessments and must clearly set out how the residents assessed needs are to be met. Risk assessments and care plans must be updated as and when changes in need or care delivery occur. Timescale of 31/03/05 not met. A record of incidence of pressure sores and of the treatment provided must be kept. Timescale of 31/03/05 not met. Records must be kept of any nursing interventions. This would include monitoring of blood glucose levels. Records must be kept of all medicines leaving the custody of the home e.g. passed to residents for self medication, relatives, hospital admission etc. The administration of creams and other external products must be recorded. Medication doses must not be prepared in advance of administration. Guidelines issued by the Nursing and Midwifery Council and the Royal Pharmaceutical Society of Great Timescale for action 30/06/05 2. 7 14(2)(b) 15(2)(c) 30/06/05 3. 8 17(1)(a) Schedule 3 17(1)(a) Schedule 3 13(2) 17(1)(a) Schedule 3 30/06/05 4. 8 30/06/05 5. 9 30/06/05 6. 9 13(2) 03/06/05 Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 23 7. 8. 29 30 Schedule 2 18(1)c)(i) 9. 30 & 38 18(1)c)(i) 13(4) 10. 38 23(2)c) Britain should be adhered to by all staff. Documentary evidence of staff training and qualifications must be kept on staff files. All staff must receive structured induction training relevant to their role. This includes nurses working part time on the bank. Staff must be provided with updated training in all safe working practice topics. The registered person must make suitable arrangements for training of staff in first aid. Timescale of 08/06/04 not met. The registered person must ensure that any equipment used by residents or staff is maintained and in good working order. This refers to portable electrical appliances. 31/07/05 30/06/05 30/09/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 2 3 9 Good Practice Recommendations Residents should be provided with a contract or terms and conditions of residency. The pre-admission assessment should provide a clear picture of the residents needs. A comprehensive risk assessment should be carried out prior to enabling residents to self-medicate. This should be reviewed regularly and supported by monitoring to ensure compliance. Photographs of residents should be kept with the Medicine Administration Record charts to reduce risk of administration errors. Par time nursing staff should be provided with induction training which includes the procedures for reporting any allegation or incident of abuse. The registered person should seek advice with regard to the validity of work permits for part time bank staff. F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 24 4. 5. 6. 9 18 29 Hollymount Nursing & Residential Care Home 7. 8. 30 31 The induction training programme for care staff should meet the National Training Organisation specifications. The registered manager should commence training to NVQ level 4. Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st floor, Unit 4 Petre Road Calyton-Le-Moors, Accringotn Lancashire. BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hollymount Nursing & Residential Care Home F57 F07 S22514 Hollymount V224148 020605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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