Inspection on 03/01/08 for Holmdale Terrace

This inspection was carried out on 3rd January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmdale Terrace 23/01/07

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 3rd – 10th January 2008 4:30 Holmdale Terrace DS0000010736.V355984.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.V355984.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.V355984.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.V355984.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) 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 2008 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.V355984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection and took approximately three and a half hours. One member of staff was on duty and provided me with every assistance throughout the visit. The manager was not available on the day of the inspection, but I spoke with her a few days afterwards to confirm compliance with some outstanding requirements from the previous inspection. I undertook a tour of the building, spoke with all the residents (albeit only briefly to some), one staff member and the manager. I also observed the interaction between people living at the home and the staff. Further information was obtained by an inspection of the documentation kept in the home, including care plans, and health and safety documentation. Information provided in the Annual Quality Assurance Assessment for the home and surveys completed by two relatives and one healthcare professional, were also taken into account. What the service does well: People have the opportunity to visit the home prior to moving in, and the home has clear and detailed assessments and care plans. The staff have a good understanding of people’s needs and residents have written contracts of terms and conditions, which are signed and up-to-date. People have access to a variety of activities and are offered varied and balanced meals. Staff support people 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 people are consulted through regular tenants meetings. 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 recommendations from the CSCI to improve outcomes for people. and 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.V355984.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care plan for one person must be reviewed at least every six months and all people living at the home must receive adequate support with the care of their finger and toenails. The practice of staff dispensing medication into weekly medication aids for residents must stop, as this places residents at greater risk of mistakes in their medication. Stronger lighting must be provided in several rooms, and a number of minor repairs must be undertaken in resident’s rooms. A new coffee table and rug must also be provided in the lounge. All carpets in the home must be steam cleaned on a regular basis, to ensure that there are no offensive odours in the home. The staffing numbers in the home during the night must be reviewed, with action taken to ensure that a current person’s needs are met safely. All staff must be trained in first aid and food hygiene, and the results of the most recent quality assurance audit must be sent to the local CSCI area office. It remains recommended that more choices of activities be available for people in the evenings and at weekends, and that a carpet steam cleaner be purchased for the home. Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 7 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.V355984.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.V355984.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People thinking about living in the home and their representatives have a range of information to allow them to make an informed choice about living at home. They are assessed before they move into the home so that the home can identify the support and resources necessary to address their needs effectively. EVIDENCE: A current copy of the statement of purpose was available, which meets the national minimum standards as appropriate. The residents’ brochure is also well laid out and up to date, and residents spoken to confirmed that they had received copies of this document. No new residents had been admitted since the previous inspection. Three 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 staff member interviewed had a good understanding of the individual residents’ needs, and where important assessment information was recorded. Holmdale Terrace DS0000010736.V355984.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 People who use this service experience adequate outcomes in this area. 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 to be as independent as possible. Detailed care plans and risk assessments are available for all people living at the home, but insufficiently frequent review of one person’s care planning information may place them at risk of not having their care needs adequately met. EVIDENCE: Three people’s case notes were inspected and these were generally found to be detailed and up to date. Detailed risk assessments were also available for all residents. Care plans that I inspected were based on residents’ individual and changing needs. I 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 person, whose needs had continued to increase significantly within the last few months, had not been reviewed within the last Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 11 six months 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 person had a number of identified goals on which progress was being monitored and support provided by staff was clearly recorded. Signatures indicated that people 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 continue to be discussed including activities, relationships and current affairs. Residents demonstrated that they could make decisions and choices about their daily lives during the inspection. On the day of the inspection residents were seen undertaking a range of activities, including cooking, going out, reading and watching television. Each resident has a weekly programme of activities including a variety of day-care activities. Holmdale Terrace DS0000010736.V355984.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home supports people to take part in activities of their choice including those that are community based. The development and support of people’s personal relationships is taken seriously by the home and residents are encouraged to enjoy a healthy diet. EVIDENCE: On the day of the inspection, some residents were out at day activities such as supported employment and a drop-in group, and others had chosen to stay at home. I spoke with one person who told me that they enjoyed going to the local shops, Wood Green shopping centre and eating out regularly. Records of resident’s activities showed that individuals had also been out for walks, shopping, to a local church, gardening, cooking and on a day trip to Brighton. Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 13 Staff had been arranging a music group and film group for people in the home. However these had not been very popular, to the point that the music group was discontinued and only one or two residents attend the film group. As recommended a new source of videos had been found following the previous inspection. However the main problem is that residents have very tastes in music and films and it has been very difficult to find a consensus on what to watch or listen to. Occasional games of bingo are also offered to residents. However it remains recommended that some new activities be offered to residents, who are no longer interested in those currently available. Given the differing tastes and preferences of people living at the home, it may be better to offer one to one activities inside or outside of the home, rather than group activities. Evidence was available that one resident continues to be supported to celebrate Jewish festivals such as Chanukah during which they are assisted to light candles and eat fried foods such as doughnuts, if they so which. 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. However records of activities do not indicate that there is much increased activity on these days. Residents and the staff member told me 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 me inspector that they enjoyed varied meals of their choice, and I saw one person cooking for themself on the day of the inspection. The home’s 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. I noted that fresh fruit and vegetables were available in the home. The residents’ involvement in the completion of the weekly menu is evidenced in the tenants meetings, which take place each week. More choices of evening meals were being incorporated on the menu as recommended at the previous inspection. 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.V355984.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. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents continue to 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, however insufficiently rigorous monitoring and recording may place people at risk of harm. EVIDENCE: People that I spoke with were generally positive regarding the support provided from staff working in the home. Residents’ files indicated that support was given to access appropriate medical services. I 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 have continued to increase within the last year, had clearly recorded visits with their local GP and consultant psychiatrist and psychiatrist as appropriate. I was concerned to observe one person with very long fingernails and another with very long toenails during the inspection. Although there was recorded evidence that the latter received support to attend a chiropodist, the frequency Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 15 of these appointments clearly needed review. Staff advised that the other person receives staff support to trim their fingernails, and this would be addressed as soon as possible. The records in relation to the administration of medication, and the storage of medication were generally found to be in order. However medication administration records did not include details of all medicines already in stock when new stocks of medicines are received. This was the case for a PRN (as and when) medicine prescribed for challenging behaviour. It is required 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. As recommended, the temperature at which medicines are stored was being recorded daily, to ensure that this does not exceed 25°C. However I was concerned to note that staff have been secondarily dispensing medicines from their original containers (as provided by the pharmacists) into dossett boxes, to aid people who are learning to self-medicate. Whilst it is clearly positive that residents are being encouraged to self-medicate, the practice of staff secondarily dispensing medication must be ceased, as it places people at an increased risk of error in their medication. Dossett boxes should therefore be filled by pharmacy staff instead. Until this is arranged, at least two staff must sign to indicate that they have checked the contents of any medicines secondarily dispensed into dossett boxes. Holmdale Terrace DS0000010736.V355984.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): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People feel that their views are listened to and acted upon and can be confident that they will be protected from abuse. EVIDENCE: A clear record of complaints and action taken to address each issue, is available at the home. The manager had developed user-friendly forms for residents to express their views and make 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. All regular staff had undertaken adult protection and protection of vulnerable adult training. Holmdale Terrace DS0000010736.V355984.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. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from living in an adequately furnished and decorated homely setting. However their comfort is compromised by the need for a number of repairs, better lighting and improved carpet cleaning within the home. EVIDENCE: The home offers an appropriate domestic type environment. I was invited by all residents to see their bedrooms (and two independent flats) which were generally clean and tidy and contained the residents’ personal possessions reflecting their individual personalities and preferences. The kitchen was equipped with all the necessary appliances to enable residents to prepare meals and snacks, having been redecorated prior to the previous inspection. Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 18 As required at the previous inspection the bed provided for staff on sleeping-in duty at the home, had been replaced, although there remains very little space for staff sleeping-in in this area. However as noted at the previous inspection, there remained insufficient lighting in an identified resident’s bedroom. The manager advised that this person preferred lower lighting in their bedroom. This was not made clear in my discussion with this resident, however if this is the case it needs to be recorded in their care plan, and they should be asked to sign to verify that this is the case. There was also a broken shelf, lamp, and bedside unit in this room. One of the independent flats had a broken lamp and another room needed repainting. The table in the lounge area is worn, and needs replacing and the room would also benefit from a rug, to make it more comfortable for resident’s use. A tour of the building showed that there was generally a reasonable standard of cleanliness within the home. However there was an odour of urine in some areas of the home, indicating that more regular carpet cleaning is needed. All bathrooms/toilet rooms had soap provided and hand towel dispensers. There was inadequate lighting (a new bulb needed) in the downstairs shower room and the lino in this room is in need of cleaning thoroughly where it is stained. It is recommended that a carpet steam cleaner be purchased for the home. Holmdale Terrace DS0000010736.V355984.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 and 35. People who use this service experience adequate outcomes in this area. 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 knowledge and skills that staff have developed through ongoing training and support. Rigorous recruitment procedures are in place to protect residents appropriately. However a review of staffing numbers is needed to ensure that resident’s needs are fully met. EVIDENCE: The manager was not available on the day of the inspection, however in the Annual Quality Assurance Assessment she advised that all staff were trained to NVQ level 2 or above in care. The staff member on duty advised that no new staff had commenced work at the home since the previous inspection and the staff team remains the same. The staff member had a clear understanding of their roles and responsibilities at the home. Regular staff meetings are also taking place and these were recorded as appropriate. Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 20 The staff rota was inspected and I discussed the staffing levels with both staff and people living at the home. I also inspected other records within the home, including a record of times staff are called out at night when on sleep-in shifts. I was concerned to note that despite a requirement at the previous inspection, there is still a problem with staffing levels at night. Staff on sleeping-in duty at the home continue to be required to get up repeatedly in the night to meet the needs of a particular resident. Although at the last inspection it was hoped that this would be a short term problem, to be addressed by a change in medication for that resident, it is unacceptable for staff to continue working long shifts without sufficient time to sleep in between. Records indicated that this was becoming more of a problem in recent months. A requirement is restated accordingly that staffing numbers be reviewed in the light of the current needs of residents and that appropriate action be taken to provide sufficient staffing numbers in the home at night. At the previous inspection 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. A range of training had been undertaken by 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. At the previous inspection it was required that all remaining staff complete training in the protection of vulnerable adults, first aid and food hygiene. Evidence was provided that all staff had completed training in the protection of vulnerable adults as appropriate. The manager advised that staff had recently undertaken training in report writing. She said that all staff were due to undertake a refresher course in food hygiene later in the month and then in first aid later in the year. Holmdale Terrace DS0000010736.V355984.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 and 42. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is generally managed effectively and have benefited from an improvement in the records maintained to protect their finances. There are procedures in place to ensure appropriate quality monitoring of standards of care and support provided to people living at the home. Residents benefit from living in a home where their health and safety is actively promoted and protected. EVIDENCE: The home’s manager 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. Since the previous Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 22 inspection, a deputy manager had been appointed for the home, so that there are clear lines of accountability in the absence of the manager. Reports of regular monthly unannounced visits to the home by the responsible individual for the provider organisation are sent to the local CSCI area office as appropriate. The manager advised that 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. A summary of the outcome of this quality assurance audit must 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. Evidence was provided to the CSCI that the recording of all monies spent, had been reviewed including recording of a particular resident’s agreement for a particular purchase. Records relating to fire tests and drills were up-to-date and carried out regularly. 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. As required at the previous inspection all perishable items stored in the refrigerator were dated as to when they were placed there, or their expiry dates and the upstairs freezer had been defrosted. Holmdale Terrace DS0000010736.V355984.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 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 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 2 3 2 X 3 X 2 X X 3 X Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 the care plan for an identified service user (whose needs are increasing significantly) is reviewed at least six-monthly and that this is recorded. The registered persons must ensure that all service users receive adequate support with the care of their finger and toenails. The registered persons must ensure that the practice of staff secondarily dispensing medication is ceased, and that this is undertaken by pharmacy staff instead, if deemed necessary. Until this is arranged, at least two staff must sign to indicate that they have checked the contents of any medicines secondarily dispensed. The registered persons must ensure that sufficient lighting is provided in the identified service user’s bedroom, or if DS0000010736.V355984.R01.S.doc Timescale for action 15/02/08 2. YA19 12(1) 01/02/08 3. YA20 13(2) 08/02/08 4. YA24 23(2cp) 15/02/08 Holmdale Terrace Version 5.2 Page 25 they do not wish for this, that this is recorded in their care plan and they sign to confirm this. (Previous timescale of 02/03/07 not met). The broken shelf, lamp and bedside unit in this person’s room must also be repaired. Another identified service user’s room must be repainted, and the lamp in a service user’s room on the ground floor must be repaired. Adequate lighting must also be provided in the downstairs shower room. The registered persons must 21/03/08 ensure that the lino in the downstairs shower room is cleaned thoroughly where it is stained. A new coffee table and rug must also be provided in the lounge. The registered persons must ensure that all carpets in the home are steam cleaned on a regular basis, to ensure that there are no offensive odours in the home. The registered persons must ensure that staffing numbers in the home during the night are reviewed in light of current service user needs. (Previous timescale of 02/03/07 not met). The registered persons must ensure that all staff are trained in first aid and food hygiene. (Previous timescale of 11/05/07 not met). DS0000010736.V355984.R01.S.doc 5. YA24 23(2cd) 6. YA30 23(2d) 15/02/08 7. YA33 18(1a) 22/02/08 8. YA35 18(1ci) 13(4,6) 21/03/08 Holmdale Terrace Version 5.2 Page 26 9. YA39 24 The registered persons must 07/03/08 ensure that the results of the most recent quality assurance audit are sent to the local CSCI area office. 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. Refer to Standard YA12 YA20 Good Practice Recommendations It is recommended that more choices of activities be available for service users in the evenings and at weekends. It is recommended that all 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. It is recommended that a carpet steam cleaner be purchased for the home. 3. YA30 Holmdale Terrace DS0000010736.V355984.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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