Inspection on 23/01/07 for Holmdale Terrace

This inspection was carried out on 23rd January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmdale Terrace 03/01/08

Holmdale Terrace 30/01/06

Holmdale Terrace 30/11/04

Holmdale Terrace 05/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holmdale Terrace 4 Holmdale Terrace Stamford Hill London N15 6PP Lead Inspector Susan Shamash Key Unannounced Inspection 23rd January 2007 12:20 Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmdale Terrace Address 4 Holmdale Terrace Stamford Hill London N15 6PP 020 8809 3638 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) Tulip Mental Health Group Alberta Yondah Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Physical disability (2) of places Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 6 adults of either gender who have a mental disorder (MD) 2 of whom may also have a physical disability (PD) 30th January 2006 Date of last inspection Brief Description of the Service: Holmdale Terrace is owned by Circle 33 Housing Association and operated as a residential home by Tulip Mental Health Group. The home was registered in 1995 and provides care and accommodation for six people with mental health problems. The home is a terraced property located near a railway line in a quiet street in the Stamford Hill area, with shops near by. There are four single rooms and two semi-independent studio flats, which include a lounge/kitchenette and bedroom. There are two bathrooms in the house; the downstairs bathroom has been adapted to provide a walk in shower. There is a communal lounge on the first floor. The kitchen is bright and has a large wooden dining room table and chairs in the middle. Staffing at the home consists of a project manager, deputy project manager and two project workers. There are three members of staff on the early turn shift and one member of staff on the late turn shift between 5pm and 9.30pm. The home now provides an additional member of staff two evenings per week to support service users to undertake activities in the community. The principle aim of the home is to provide the emotional and practical support necessary to enable service users to exercise a degree of independence and self-determination in their lives. The weekly fees for the home as of January 2007 are £819.28 per week. Current CSCI inspection reports can be obtained from the home’s office or the CSCI website at www.csci.org.uk Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took approximately seven and a half hours. A staff meeting was held during the inspection, but staff and the manager Alberta Yondah, provided the inspector with every assistance throughout the day. The inspector undertook a tour of the building, spoke with four residents and two staff members on duty as well as observing the interaction between the residents and the staff at the home. Further information was obtained by an inspection of the documentation kept in the home, including care plans, and health and safety documentation. Written feedback forms were received from five care managers, one health care professional and four residents. These generally provided very positive information about the home. What the service does well: Residents have the opportunity to visit the home and the home has clear and detailed assessments and care plans. The staff have a good understanding of residents’ needs and residents have written contracts of terms and conditions, which are signed and up-to-date. Residents have access to a variety of activities and are offered varied and balanced meals. Staff support residents in relation to contact with family and friends and provide residents with appropriate support to take their prescribed medicines. The cultural needs of residents are also supported sensitively. The home operates effective procedures in relation to complaints and ensures that residents are consulted through regular tenants meetings. The home environment is clean and furnished and decorated appropriately. Staff are supervised regularly and receive a high standard of training to meet the needs of residents effectively. The home has a good history of compliance with requirements and recommendations from the CSCI to improve outcomes for residents. The home is managed effectively with quality assurance systems in place for the home to ensure that it meets a high measurable standard. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? All requirements appropriately. from the previous inspection had been addressed As required at the previous inspection, risk assessments had been updated to include information about residents not reacting to the fire alarm. Staff had also improved the frequency of recording activities undertaken by residents. The shower flooring had been replaced. A blind had been fitted at the kitchen window and comfortable seating had been provided in the kitchen area. The kitchen had also been redecorated and the smoking room had been redecorated and the chairs replaced. The purpose and function document had been updated as required. The London Fire and Emergency Planning Authority had been consulted with in relation to action to be taken when residents do not leave the home when the fire alarm is sounded and in relation to the homes Disaster Recovery Plan. Finally, a detailed business and development plan had been produced for the home. What they could do better: A full and up to date care plan and risk assessments must be produced for the identified resident. Sufficient lighting must be provided in the identified resident’s bedroom and a new bed must be provided for staff on sleep-in duty. Staffing numbers in the home during the day and night must be reviewed in light of current residents’ needs. All staff must be trained in the protection of vulnerable adults, first aid and food hygiene. The home’s policies regarding the safekeeping of residents’ monies, and records of monies spent, must be reviewed. Evidence must be provided regarding an identified resident’s agreement to contributing towards the cost of carpet cleaning at the home. Cheese and meat slices stored in the refrigerator and all meat and poultry stored in the freezer must be labelled with the date of opening/freezing and expiry dates. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 7 It is recommended that more activities be available for residents in the evenings and at weekends, and that there be more choices of evening meal. It is recommended that medicines already in stock be recorded on new medication administration records, and that the temperature at which medicines are stored should also be monitored daily. Finally the results of the next quality assurance audit should be sent to the local CSCI area office. 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 be made available in other formats on request. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have a range of information to allow them to make an informed choice about living at home. Prospective residents’ needs are also assessed before they move into the home so that the home can identify the support and resources necessary to address these needs. EVIDENCE: At the previous inspection it was required that the purpose and function document in the statement of purpose be updated. A copy the updated statement of purpose was sent to the local CSCI area office as required, and this meets the national minimum standards as appropriate. The inspector noted that the residents’ brochure is also well laid out and up to date. No new residents had been admitted since the previous inspection. Four residents’ files were inspected and all contained clear assessment information that is being reviewed on a regular basis. The assessment process includes a six weeks assessment, which involves looking at areas including daily living skills and budgeting. The manager and staff interviewed showed understanding of the individual residents’ needs. that they had a good Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is good at enabling residents to make decisions for themselves about what they want to do, and in taking calculated risks so the residents are helped to be as independent as possible. However although detailed care plans and risk assessments are available for the majority of residents, insufficiently detailed care planning information for one identified resident may place them at risk of not having their care needs adequately met. EVIDENCE: Four residents’ case notes were inspected and these were generally found to be detailed and up to date. Detailed risk assessments were also available for the majority of residents. At the previous inspection the inspector took part in a discussion with the manager and an identified resident who does not attempt to leave the home during fire drills but prefers to remain in their bedroom. As required at that inspection, this information had been recorded in this resident’s care plan and the attached risk assessment. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 11 The care plans were based on residents’ individual and changing needs. The inspector saw evidence that the majority of care plans and accompanying risk assessments were being reviewed regularly. However the care plan and risk assessments for one resident, whose needs had increased significantly within the last few months, had not been updated as appropriate, although there was evidence that medical reviews had been undertaken for this resident and that all staff were aware of their changed needs. A requirement is made accordingly. Clear records were maintained of each resident’s Care Programme Approach meeting as appropriate, with evidence that actions identified were being followed up by staff. Each resident had a number of identified goals on which progress was being monitored and support provided by staff was clearly recorded. Signatures indicated that residents were being consulted about their care plans, and this was confirmed by those spoken to. Tenants meetings, to discuss issues relating to the residents, take place regularly and records were available of these meetings as appropriate. A range of topics are discussed including activities, relationships and current affairs. Residents demonstrated that they could make decisions and choices about their daily lives during the inspection. For example, one resident had decided that they wished to learn to speak Hebrew. On the day of the inspection residents were seen undertaking a range of activities. Each resident has a weekly programme of activities including a variety of day-care activities. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports residents to take part in appropriate activities including those that are community based. The development and support of residents’ personal relationships is taken seriously by the home, as is their encouragement of residents to enjoy a healthy diet. EVIDENCE: On the day of the inspection, one resident went out to the bank and to buy a take away lunch for other residents that were at home. Others were out at day activities such as supported employment or had chosen to stay at home. The inspector spoke with a resident who confirmed that they enjoyed going to the local shops, Wood Green shopping centre and eating out regularly. Residents had also been on trips to the pub, a local museum, the West End and on holiday to Eastbourne since the previous inspection. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 13 One resident goes to a club where they undertake activities such as news and views, internet, a lifestyle group, and creative arts. Evidence was available that staff arrange a music group and offer residents a game of bingo once weekly, although these activities had been less popular of late. At the previous inspection it was noted that the activity reports did not fully reflect the range of activities that residents are involved in. Clear records were now being made of activities undertaken by residents. However it is recommended that some new activities be offered to residents, who are no longer interested in those currently available. Although regular video nights are scheduled for residents, records indicated that there was frequently difficulty in coming to a consensus about which film to watch. Some residents told the inspector that this was because they had already seen all the videos in the home. It is recommended that membership of a video club be considered for the home so that more choices might be available to residents. Evidence was available that one resident was being supported to celebrate Jewish festivals such as Chanukah during which they were assisted to light candles and eat fried foods such as doughnuts. An Xmas party was also held for residents at the home. The staff rota indicates additional staffing available on two evenings each week to allow residents involvement in activities to take place. Residents told the inspector that they are supported to maintain contact with their family and friends. Care plans and the visitors’ record for the home confirmed this. Residents told the inspector that they enjoyed varied meals of their choice. Inspection of the menu indicated that a balanced diet is provided and staff are aware of each resident’s preferences in relation to their meals and these are clearly identified in their individual care plans. On the day of the inspection the inspector noted that fresh fruit and vegetables were available. The inspector observed that residents are supported to prepare snacks in the evening and have a hot meal at lunchtime. The residents’ involvement in the completion of the weekly menu is evidenced in the tenants meetings, which take place each week. However it is recommended that more choices of evening meal be provided for residents as records indicated that evening meals frequently consist of soup and sandwiches. There was evidence available that residents had visited local restaurants, one resident enjoys Caribbean foods served regularly at the home, including rice and peas, and another enjoys Jewish cultural foods of their choice on a regular basis. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate support to meet their physical and emotional health needs. They benefit from effective systems in place with regard to the administration of their medication. EVIDENCE: The residents spoken with were very positive regarding the support provided from staff working in the home. Residents’ files indicated that support was given to access appropriate medical services. The inspector saw evidence of regular dental and optician appointments for all residents, in addition to records of blood tests and contact with their GPs. One resident, whose needs had changed significantly within the last few months, had clearly recorded visits with their local GP and consultant psychiatrist as appropriate. The records in relation to the administration of medication, and the storage of medication were found to be in order. However medication administration records did not include details of medicines already in stock when new stocks of medicines are received. It is recommended that medicines already in stock Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 15 be recorded as ‘carried forward’ onto new medication administration records, so that there is an accurate record of all medicines in stock at all times. It is also recommended that the temperature at which medicines are stored should be recorded daily, to ensure that this does not exceed 25°C. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that their views are listened to and acted upon and can be confident that they will be protected from abuse. EVIDENCE: The record of complaints was inspected and there had been four complaints made since the previous inspection. Each complaint had been appropriately recorded with evidence of appropriate action taken within the set timescales of the home’s complaints procedure. The manager had developed user-friendly forms in relation to residents expressing their views and making the decision as to whether they want to make a formal complaint. This also includes a complaints response form, a dissatisfaction response form and comments form. There is an adult protection procedure, which is in place and meets the requirements of this Standard. Guidance regarding whistle blowing is contained in a separate policy and procedure. The majority of staff had undertaken adult protection and protection of vulnerable adult training. However inspection of three staff files indicated that one staff member had not undertaken this training. A requirement is made accordingly. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a comfortable, well furnished and decorated, homely setting. There is a high standard of cleanliness within the home. EVIDENCE: The home offers an appropriate domestic type environment. The inspector was invited by three residents to see their bedrooms, which were clean and tidy and contained the residents’ personal possessions reflecting their individual personalities and preferences. The inspector also visited one of the independence flats within the home. A number of improvements to the home environment, had been made since the previous inspection. As required at the previous inspection, the ground floor shower flooring had been replaced with a non-slip surface. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 18 The kitchen was equipped with all the necessary appliances to enable residents to prepare meals and snacks. As required at the previous inspection, the kitchen had been redecorated, a blind had been fitted at the window and some additional comfortable seating had been provided to make this area more homely. The smoking room on the top floor of the house had been redecorated and some new comfortable chairs were provided. The office had also been redecorated and the carpet had been replaced. However staff advised that the bed provided for staff on sleeping-in duty at the home, was broken. A requirement is made accordingly, and the manager advised that a new bed was already on order. The only issue of concern noted by the inspector whilst inspecting in the home was insufficient lighting in an identified resident’s bedroom. A requirement is made accordingly. A tour of the building showed a good standard of cleanliness within the home and appropriate hygiene procedures including soap and hand towels in all toilets and bathrooms. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from clearly set out staff roles and responsibilities, and the knowledge and skills, which staff have developed through ongoing training, support and supervision. However a review of staffing numbers is needed to ensure that residents’ needs are fully met in the light of recent changes. Rigorous recruitment procedures are in place to protect residents appropriately. EVIDENCE: The manager informed the inspector that two staff were undertaking NVQ qualifications. Three staff files were inspected and one included evidence of completion of an NVQ level 3 qualification in care. Staff spoken to had a clear understanding of their roles and responsibilities at the home. Supervision records were inspected indicating that all staff are receiving regular supervision. Regular staff meetings are also taking place and these were recorded as appropriate. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 20 The staff rota was inspected and found to be in order. However discussion with staff members indicated that those on sleeping-in duty at the home had recently been required to get up repeatedly in the night to meet the needs of a particular resident. Although it was hoped that this was a short term problem, to be addressed by a change in medication for that resident, it is clearly unacceptable for staff to work long shifts without sufficient time to sleep in between. A requirement is made accordingly that staffing numbers be reviewed in the light of the current needs of residents. Recruitment information for staff members indicated that rigorous checks are carried out to ensure the suitability of staff including enhanced CRB (Criminal Records Bureau) disclosures, two verified references and identity documents. Staff files indicated that a range of training is undertaken by all staff members including fire safety, health and safety, equality and diversity, medication administration, service user involvement, assessing needs, mental health legislation and managing violence and aggression. However although the majority of staff had undertaken training in the protection of vulnerable adults, first aid and food hygiene, at least one staff member was found still needing to undertake each of these courses and a requirement is made accordingly. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is managed effectively with appropriate quality monitoring in place to ensure that their views are taken into account. An improvement is needed in the recording and management of residents’ finances to ensure that they are fully protected from abuse. Residents benefit from living in a home where their health and safety is actively promoted and protected. EVIDENCE: The home’s manager is in the process of completing her registered manager’s award at NVQ level 4, and is experienced at working in the field of mental health. Staff and residents spoke positively about the way in which the home is managed and the support provided by the manager. However the lack of a Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 22 deputy manager continues to be an area which needs to be addressed, so that there are clear lines of accountability in the absence of the manager. The registered provider had provided a written annual development and business plan for the home to the CSCI as appropriate. Reports of regular monthly unannounced visits to the home by the responsible individual for the provider organisation are also sent to the local CSCI area office. Quality assurance questionnaires had been completed by all residents in the home as appropriate, and a detailed system of auditing the quality of systems had been completed for the home. The registered persons are reminded that the results of the next quality assurance audit must also be sent to the local CSCI area office. Inspection of residents’ monies stored by the home for safe-keeping indicated that all transactions had been recorded up to date, and were signed for by staff and residents as appropriate. The inspector was also able to check that residents’ bank/building society accounts tallied with records of monies maintained by the home. However the inspector was concerned to note that one resident had paid for carpet cleaning in the home on at least one occasion, without any written agreement being put in place to explain this. The manager explained the reason for this measure, and advised that some of the money was to be reimbursed to this resident. However it is of concern to the inspector that insufficiently rigorous procedures are in place to protect the resident in question appropriately. It is therefore required that policies regarding the safekeeping of residents’ monies and recording of monies spent, must be reviewed. Evidence must also be provided to the local CSCI area office regarding the identified resident’s agreement, and that of their care manager/advocate, to recompensing the home for carpet cleaning. Records relating to fire tests and evacuations were up-to-date and carried out regularly. On occasions when residents have been reluctant to leave their rooms during fire drills, records seen showed that staff had worked hard in meetings and individual key worker sessions to impress upon them the importance of fire drills to their safety. The manager had also ensured that these identified risks were recorded in the residents’ care plans and risk assessments. As required the manager had consulted with the London Fire and Emergency Planning Authority in relation to the agreed action to be taken in this situation and in relation to The Disaster Recovery Plan. The homes gas safety, electrical installation and portable appliances testing certificates was seen and found to be in order. Records of accidents and incidents were clearly documented as appropriate and risk assessments were in place for the home environment. The inspector was concerned to note the storage of cheese and meat slices in Tupperware containers in the refrigerator, without a date as to when they were Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 23 placed there, or their expiry dates. A piece of chicken was also found stored in the freezer without a label indicating the date of freezing or expiry date. A requirement is made accordingly. The upstairs freezer should also be defrosted to ensure that it is functioning effectively. Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 25 CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 2 X Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(2) Requirement The registered persons must ensure that a full and up-to-date care plan and risk assessments are produced for the identified service user. The registered persons must ensure that sufficient lighting is provided in the identified service user’s bedroom. Timescale for action 02/03/07 2. YA24 23(2cp) 02/03/07 3. YA33 18(1a) 4. YA35 18(1ci) 13(4,6) 5. YA41 17(2) Schd 4(9) 20(3) A new bed must also be provided for staff on sleep-in duty. The registered persons must 02/03/07 ensure that staffing numbers in the home during the day and night are reviewed in light of current service user needs. The registered persons must 11/05/07 ensure that all staff are trained in the protection of vulnerable adults, first aid and food hygiene. The registered persons must 09/03/07 review the home’s policies regarding the safekeeping of service user monies and records of monies spent. Evidence must be provided to the local CSCI area office regarding the identified service user’s DS0000010736.V322945.R01.S.doc Version 5.2 Page 27 Holmdale Terrace 6. YA42 16(2j) agreement and that of their care manager/advocate to recompensing the home for carpet cleaning. The registered persons must ensure that cheese and meat slices stored in the refrigerator and all meat and poultry stored in the freezer are labelled with the date of opening/freezing and expiry dates, and that the upstairs freezer is defrosted. 02/03/07 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. 2. 3. Refer to Standard YA12 YA17 YA20 Good Practice Recommendations It is recommended that more choices of activities be available for service users in the evenings and at weekends and that they consider joining a local video club. It is recommended that more choices of evening meal be provided for service users and that these be recorded. It is recommended that medicines already in stock be recorded as ‘carried forward’ onto new medication administration records, so that there is an accurate record of all medicines in stock at all times. The temperature at which medicines are stored should also be recorded daily, to ensure that this does not exceed 25°C. The registered persons are reminded that the results of the next quality assurance audit should be sent to the local CSCI area office. 4. YA39 Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Holmdale Terrace DS0000010736.V322945.R01.S.doc Version 5.2 Page 29 - 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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