Inspection on 04/08/06 for Holme Farm Care Home

This inspection was carried out on 4th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Holme Farm Care Home 01/08/07

Holme Farm Care Home 28/02/06

Holme Farm Care Home 15/11/05

Holme Farm Care Home 20/01/05

Holme Farm Care Home 10/08/04

Holme Farm Care Home 30/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Holme Farm Care Home 9 Church Street Elsham Brigg North Lincolnshire DN20 0RG Lead Inspector Ms Matun Wawryk Unannounced Inspection 09:00 4 August 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme Farm Care Home Address 9 Church Street Elsham Brigg North Lincolnshire DN20 0RG 01652 688755 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) residential_home.elsham@fsmail.net Mr Anthony John Steeper Mrs Janet Steeper Mr Anthony John Steeper Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Registered Manager commences the Registered Managers Award and NVQ level 4 in Care before 31st October 2005. 28th February 2006 Date of last inspection Brief Description of the Service: Holme Farm is situated in the small village of Elsham. The home has open views across fields and fishing ponds and very pleasant accessible gardens. The home is registered for 20 male/female service users over the age of 65 years. The home is well maintained and provides a very homely environment. The service users accommodation is on one level and bedrooms are all single occupancy. Three of the bedrooms have ensuite facilities. The home has two lounges and a dining room. The home does not offer nursing care. Service users health needs are met with the assistance of other health care professionals for example general practitioners and district nurses. Information about the home and its services can be found in the statement of purpose and residents’ guide, both these documents are available from the manager of the home. Information detailed in the pre inspection questionnaire indicates the home charges between £335 and £555 per week. The home charges third party topup fees for bed-sit and ensuite rooms. In addition residents are expected to pay for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in July 2006. Mrs Matun Wawryk carried out the site visit. The visit lasted seven and a half hours. Prior to the visit to the home the inspector had sent out a selection of surveys to residents, some family members, staff members and professional visitors to the home. The inspector issued 18 resident questionnaires out of which 3 were returned, 20 staff questionnaires of which 8 were returned. Surveys questionnaires were also sent to two GP practitioners and four health and/or social care professionals. These were analysed on their return and comments checked out during the inspection. Some of the comments received by these people have been included in the report. Information received by the Commission over the last few months was also considered in forming a judgement about the overall standards of care within the home. Throughout the day the inspector spoke to nine residents users to gain a picture of what life was like for people who lived at Holme Farm. The inspector also spoke with the manager, a senior care worker, two carer workers and a cook. Documentation in relation to the assessments people had prior to admission and the care plans produced to meet assessed needs were examined. Also examined were medication practices, activities provided, nutrition, complaints management, fire safety, general cleanliness, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked to see that residents privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in their environment. What the service does well: The home was pleasantly decorated and furnished with separate lounges for people to sit and join in activities. The main garden to the front of the building was well maintained and the rear garden had places for people to sit and relax in. The home was very clean and tidy and domestic staff work hard to maintain the high standards. Residents spoken to were happy with the cleanliness of Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 6 their bedrooms and the home in general. Two residents said ‘you will not find a cleaner home anywhere’ There was a very relaxed and homely atmosphere in the home, residents were observed to be very settled and comfortable in their surroundings. All of the residents who returned a questionnaire said they were satisfied with the overall care provided by the home. One residents said ‘the care provided is excellent, you could not get better care anywhere else’ Residents and staff spoken to commented on the approachability of the manager. All those spoken to said the manager was friendly and efficient. Residents commented that they were offered a good choice of meals and that they enjoyed the quality of food. Specific wishes were catered for and residents said they had plenty to eat and drink throughout the day. One resident said it’s the best food I’ve ever tasted’ another resident said ‘the food lovely. Residents said that their family and friends were made to feel welcome by staff and that they can visit when they please. All the relatives who returned a questionnaire said they were satisfied with the overall care provided by the home. One relative wrote ‘excellent care home, nothing but praise for the care received from the home and staff’ Residents said they had good access to professional medical support when needed. Residents also said that they were able to access external services such as chiropodist, dentists and opticians again as needed. What has improved since the last inspection? Staff had accessed more moving/ handling, fire safety and first aid training; this was needed to ensure the health and safety of residents and staff. The way the manager supervises staff had improved, staff were getting more regular and formal supervision. This was needed so that the manager can show how he was assessing and monitoring the abilities of staff in the home. The way staff were recruited had improved. This means the home takes appropriate action to safeguard and protect residents from harm by operating safe recruitment practice. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 7 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. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that residents’ needs were assessed prior to admission and included the resident and/or their representatives in the assessment process. EVIDENCE: The home had a statement of purpose and service user guide, both these documents required minor amendment to ensure all information required by National Minimum Standard 1 and Schedule 1 of the Care Homes Regulations is detailed. The manager gave an assurance that both documents would be reviewed within the next two months. Four resident files were case tracked; pre-admission assessments were evidenced and residents’ needs had either been assessed in their own homes or in hospital. The admission procedure was adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 10 Some residents spoken to confirmed that they had taken the opportunity to visit the home prior to admission although most said that their families or friends had visited the home to assess its suitability, which had been a satisfactory arrangement. One resident said ‘you could not get a better home than this’ another resident said my son went to see several homes and this home was the best by far’ There was no evidence to show that the home formally wrote to residents or their representatives following assessment to confirm the home could meet the residents identified needs. This should now happen. The manager said that all residents had received a statement of terms and conditions/contract and this was backed up by comments from residents. copies of contracts were maintained in the home. Seven of the nine residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals. Residents indicated that they were satisfied with the care at the home and all those who spoke to the inspector said the staff were caring and attentive to their needs. With the exception of the manager all the care workers employed in the home were female, this means the home may not be able to accommodate residents choices concerning the gender of the person providing personal care. This said none of the residents spoken to were concerned about this matter. The home does not provide intermediate care therefore NMS 6 is not applicable. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. Residents personal care needs were met in a way that respected privacy and dignity and the home ensured that people had access to health care services. EVIDENCE: Case Tracking took place for four residents. The methodology used was a physical examination of care plans, written surveys to residents, relatives and health and social care professionals, and direct observation on the day. Care plans examined in detail indicated that the needs highlighted in assessments were planned for. Care plans were updated as needs changed and evaluated on a regular basis. There was evidence that some care plans had been signed by the resident or their representative and referred to levels of independence, privacy and dignity. It was noted that residents care plan had not be updated to reflect a change in needs. The inspector advised that this Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 12 individual care plan should be reviewed and an assurance was provided that this would be carried out. Three residents spoken to knew they had care plans and one spoke of having a review with their relative. Other residents spoken to confirmed that they were aware of their care programmes but had no interest in reading them. There were risk assessment tools for mobility, falls, tissue viability, medication, nutrition and general issues; high risk areas had been identified and care plans were in place to support appropriate care provision in most cases. The manager confirmed that all the residents were registered with a General Practitioner (GP). Six residents spoken to said that they had good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. Records showed some residents had access to outpatient appointments at the hospital and records showed that they have an escort from the home if needed. The home obtains its medication though a prescribing general practitioner. Information from the pre-inspection questionnaire and discussion with the staff and manager indicates that all those responsible for giving out medication had undergone medication training. Medication systems were examined at this visit; policies and procedures were in place, which covered areas of management and administration. Record were also examined in relation to receipt, administration and disposal of medication, these were clearly maintained and there was a thorough system of stock control. The process of administrating medication was complicated, involving two staff checking medication as it was dispensed and administered. All staff responsible for administering medication has received medication training. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this home. Not all the residents were seen to experience a full life with opportunities to take part in varied activities. Residents receive a healthy, varied diet according to their assessed needs and choices. EVIDENCE: Residents spoken to said daily routines in the home were flexible. Residents confirmed that they were able to choose how to spend their day. Choices and preferences were not clearly recorded in some assessments and care plans seen by the inspector. However residents spoken to confirmed that their wishes were adhered to regarding times of rising and retiring, preferences with bathing arrangement, personalising their bedrooms and general choices about meals. One resident said, “I feel that I am listened to and that the staff take notice of me” Other residents told the inspectors that they felt safe and well cared for. The inspector observed positive interactions between staff and residents and it was clear that staff endeavoured to build positive relationships and communication appeared good. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 14 Residents’ religious needs were identified on admission in most cases. Staff reported that residents had the opportunity to access local churches or attend services held in the community. Discussion with the residents indicated that they have good contact with their families and friends and that visitors were made welcome at any time. One resident said ‘the staff are very good, they always offer my visitors a drink’ another said ‘the staff are always polite and friendly to my visitors’. Residents spoken to said they were able to see visitors in the lounges or in their own rooms. All the relatives who returned a questionnaire said they were satisfied with the overall care provided. One relative wrote ‘excellent care home, nothing but praise for the care received from the home and staff’ The does not employ an activity co-ordinator; care workers are responsible for organising activities within a group or on a one to one basis. A formal activity programme was not in place. Staff said activities provided included, bingo, quizzes, sing-a-longs, visiting entertainers and trips out. The manager also said he was in the process of allocating keyworkers two and a half hours each month to enable them to spend quality time with each resident carrying out activities of their choice. Records showed that in most cases brief social profiles, had been completed, however these had not been reviewed and updated to reflect changes in the needs and circumstances of residents. Records and feedback from residents and some staff indicated that staff may need to look in more detail at peoples social stimulation needs in order to better tailor daily activities to individual wishes, needs and capabilities of some service users. Staff had not had any particular training in organising and arranging activity programmes. This would be useful in assisting staff to assess and plan activities. The standard of the meal provision in the home was good. Weekly menus are provided, which demonstrated that a choice of meals was provided. In discussion with the inspector all the residents spoken to said that individual choices and preferences were accommodated wherever possible. Residents said they enjoyed the meals. One resident said ‘the food is the best I’ve ever tasted, another wrote ‘you could not get better food anywhere’. In discussion with the inspector staff demonstrated good knowledge of the residents food preferences. The home was not catering for any specific diets, although the cook said the home would be able to accommodate any specific religious or cultural dietary requirements of residents. The cook was aware of where to access information and guidance about diets. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement is based on evidence gathered both during and before the visit to this service. The home had a satisfactory complaints system with evidence that the residents’ were aware of the complaints process. Procedures for adult protection were in place but must be supported by a staff-training programme. EVIDENCE: An up-to-date complaints procedure was displayed prominently in the main entrance of the home and residents spoken to were able to tell the inspector who they would complaint to. The manager stated no complaints had been made in the last twelve months and records seen confirmed this. Five residents who returned a questionnaire confirmed they were aware of the home’s complaint procedure; one said they were unaware of the procedure. This may reflect a shortfall in information and understanding about the process and the manager should take steps to address this. No adult protection referrals had been made in the last twelve months. Procedures for adult protection were in place and when asked about abuse, what it was and what they would do if they suspected or saw a resident being Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 16 abused, staff answered appropriately. However interviews with staff and records evidenced that most staff had not been provided with adult protection training. This must now happen, this is needed to ensure all staff fully understand referral processes and to ensure staff are able to recognise adult protection matters. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. The home provided a clean, safe and accessible environment for residents and they had the opportunity to personalise their bedroom to their own taste. EVIDENCE: The home provides and maintains comfortable and safe facilities. All areas of the home seen by the inspector were decorated and furbished to a good standard. There was a maintenance programme in place; painting to the outside of the home was being carried out at the time of the visit and some bedrooms had also been redecorated. All areas were seen to be very clean and tidy; residents told the inspector during the visit that the home was always kept very clean. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 18 All bedrooms examined were clean and tidy and were furnished and decorated in a homely style. The residents spoken to stated that they were happy with their rooms. Many people had furnished their bedrooms with a range of personal items, some bringing in items of furniture to reflect their own individual choice and taste. Feedback from residents and staff indicated that the home was well equipped. Staff said they had access to all the equipment needed to meet the resident care needs. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality outcomes in this area are adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of residents. Although improvements had been noted in the provision of training, some staff had not completed all mandatory training for example moving and handling. Recruitment practices afford sufficient protection for residents. EVIDENCE: The home normally has three care workers and one senior on duty up to 5pm after this there is normally a senior and two care workers. Two waking staff are on duty through the night. In addition the homes employs cooks and ancillary staff. All the residents spoken to said they considered the staff had time to provide care in a timely fashion and did not feel they were unduly rushed or had to wait too long for their needs to be met. They also commented on how kind and supportive the staff were. All of the staff spoken to said they felt staffing levels were generally appropriate to enable resident needs to be met. A staff induction programme was in place and improvements had been made to the provision of staff training since the last visit. The manager and one Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 20 senior care worker had undertaken a moving and handling and basic first aid trainers’ course. In addition some staff had completed distance-learning courses in food hygiene, infection control and health and safety. Whist this was a positive development records and discussions with staff evidenced that a number of staff had still not completed some basic mandatory training for example moving and handling. In discussion the manager gave assurance training would be provided as a matter of priority. This must happen to ensure the health and safety of staff and residents. Records evidenced some staff had accessed general courses on adult protection, continence care etc. However as indicated in other section of this report a number of staff still needed to be provided with adult protection training. The home employs nineteen care workers. The manager stated that seven care workers held an NVQ qualification and three others were in the process of completing an award. This means the home will achieve the target of 50 of care workers with an NVQ as required by the National Minimum Standards. Records and staff feedback evidenced that the manager and or senior care workers had carried out individual appraisals with staff. Significant improvements were noted in recruitment and selection practice. Three staff files were examined; they were found to be in good order, they all contained the relevant documentation to comply with Schedule 2 of the Care Standards. Files of recently recruited staff demonstrated that the staff had commenced work in the home after the relevant police checks and references had been obtained. The home maintains records to support equal opportunities in their recruitment practices. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager had continued to make improvements towards his management of the administration systems. However efforts must now be made to ensure all outstanding requirements are met. The management of health and safety was generally satisfactory. However the health and safety of residents and staff was compromised because not all staff were up to date with some mandatory training for example moving and handling. EVIDENCE: The manager was in the process of completing the Registered Managers Award. The manager confirmed that on completion of this award he would complete the National Vocational Qualification level 4 in care. Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 22 Residents and staff were complimentary about how the home was run. All the residents spoken to commented on how friendly and supportive the manager was. Staff confirmed that moral was good and commented that there was a good team approach to care delivery at the home. Evidence from staff discussions indicated that the staff consider the manager to be approachable. Staff confirmed that the manager took issues raised seriously and took action to resolve matters. Staff and resident meeting were held. There was good evidence to demonstrate that the manager was focussing on improving and maintaining the management systems in the home, specifically care documentation, staff training and recruitment practises. A staff supervision policy was in place and the manager and senior carers had responsibility for carrying out staff supervision. Records for six staff were examined, these evidenced that staff were provided with formal recorded supervision. Although progress had been achieved in meeting a number of the requirement detailed in the last inspection report, a small number remained outstanding and action must be taken to address these. The home had a satisfactory quality-monitoring programme. Regular audits were carried out. Surveys were conducted with residents, their relatives, staff and professional staff. The home had also been awarded the Gold Award in the Local Authorities quality assurance system. The home had a range of policies and for health and safety and a current insurance certificate was on prominent display in the home. The home had current maintenance certificates for the fire system and fire fighting equipment. Record showed a check had been carried out on the fixed bath hoist. The inspector queried whether recommended work detailed in the ensuing maintenance report had been carried out. The manager said he had asked the company to provide a quote for the work, but stated recommended work did not compromise the integrity of the hoist. The manager confirmed that all fire doors closed properly. Accident books are filled in appropriately, and the inspector recommends that the manager completes regular audit on these to help spot any problems or recurring themes. Records for one residents identified bed rails were being used. A risk assessment had not been completed. The inspector advised that use of bedrails must be supported by clear and detailed risk assessment, which must be completed in line with guidance issued by the Medical Devices Agency. This Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 23 is needed to ensure any risk associated with using bedrails is properly assessed and planed for. Records and discussion with staff evidenced some staff had not completed mandatory training for example: moving and handling. This training must know be provided. This is needed to ensure staff know how to do things in the right way and to ensure the health safety of both residents and staff. Holme Farm Care Home DS0000002905.V306570.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x x 3 x 2 Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4&5 Requirement The registered person must update the statement of purpose and service users guide to reflect the management changes. Timescale of 31.0.2005 and 31.12.05 not met The registered manager must complete NVQ 4 in management and care. Timescale of 31.12.05 and 30/09/06 not met Timescale for action 31/10/06 2. OP31 9 31/12/06 3. OP18 13 The registered person must 31/10/06 ensure staff are provided with adult abuse training. Timescale of 31.1.06 and 30/04/06 not met The registered person must ensure staff are provided with manual handling training. Timescale of 31.12.05 and 30.4.06 not met The registered person must ensure all staff are up to date DS0000002905.V306570.R01.S.doc 4. OP3 18(1)(a) 31/10/06 5. OP38 13 31/10/06 Holme Farm Care Home Version 5.2 Page 26 with all areas of mandatory training for example fire safety, health and safety and infection control. Timescale of 31.5.06 not met 6 OP12 16(2)(n) The registered person must ensure that the range of activities is expanded to provide stimulation for all service users in accordance with need choices and abilities The registered person must ensure bedrails assessments are completed in line with guidance issued by the Medical Devices Agency 31/10/06 7 OP38 13 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations The manager should ensure work recommended, which is detailed in the maintenance log for the bath hoist is carried out Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Holme Farm Care Home DS0000002905.V306570.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!