Inspection on 19/06/06 for Holme House

This inspection was carried out on 19th June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holme House 08/05/09

Holme House 22/05/08

Holme House 30/05/07

Holme House 24/10/05

Holme House 07/06/05

Holme House 02/12/04

Holme House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 House Oxford Road Gomersal Cleckheaton West Yorkshire BD19 4LA Lead Inspector Jacinta Lockwood Unannounced Inspection 09:50 19 and 28th June 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 House DS0000026273.V301083.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 House DS0000026273.V301083.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme House Address Oxford Road Gomersal Cleckheaton West Yorkshire BD19 4LA 01274 862021 01274871702 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) Milelands Ltd Mr Jeremy Robert Martin Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user under 65 years of age - DE category 24 October 2005 Date of last inspection Brief Description of the Service: Holme House is a care home registered to provide personal care and accommodation for up to forty, male and female, older people. It is situated in the Gomersal area of Kirklees fairly close to Birkenshaw, Birstall and the M62. The original property, which has been extended and modernised for its current use, retains some original features adding to its homely feel. There is ramped access to the front door of the home and stair lifts are in place to allow access to the ground and first floor. A passenger lift is also available. There are large, well-maintained gardens to the front and rear of the property where service users are able to sit when the weather permits. Car parking is available to the front of the property. The home’s pre-inspection questionnaire received by the Commission on 05.05.06 states that the weekly fees range from £321.25 to £350.00 per week. Additional charges are made for hairdressing, newspapers and toiletries. Information about the home and the latest Commission for Social Care Inspection report are available from the home. Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit, by a regulation inspector and a regulation manager, took place over two days. The first, unannounced, visit on 19.06.06 started at 09:50 and ended at 17:00; the second visit on 28.06.06 was announced and started at 09:45 and finished at 14:10. At the time of the visits, there were 38 service users in residence. The last visit to the home was an unannounced inspection on 30.01.06 to check progress on some of the requirements and recommendations made during the last main inspection of the home on 24.10.05. It was positive to note that on 30.01.06 some progress had been made. There were still some shortfalls identified during that inspection in areas relating to health and personal care, health and safety and hygiene standards. Evidence was seen during this inspection that action has been taken to address those shortfalls. During the site visit, the inspectors spoke with 13 service users some of whom, owing to their frailty, were unable to express their views about the service; three visitors, a community nurse, five members of staff and the registered manager, Mr Jeremy Martin. Prior to this visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to a sample of 10 service users at the home, 3 were returned; their next of kin; seven were returned; GPs, four were returned; and social and health care professionals, four were returned. A completed pre-inspection questionnaire was also returned to the Commission prior to the visits. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, for example, notifiable incident reports when service users are involved in an accident or incident. The care records of four service users were inspected, including care plans, risk assessments, medication, any monies and accounting records held by the home. Other records sampled included the food menu, complaints log, staffing rota, staff recruitment and training records, maintenance records and policies and procedures. A partial tour of the building was made, including the bedrooms of four service users whose care was case-tracked as part of the inspection. The Commission would like to thank all those who contributed to the inspection process. Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some redecoration of communal areas has taken place and as noted above, this is to a good standard. Improvements have been made to record keeping, generally. Pre-employment information including Criminal Record Bureau and Protection of Vulnerable Adults checks are obtained before a person starts work to ensure they are safe to work with vulnerable adults. And staff receive protection of vulnerable adults training. A new medication system has been introduced which means that less staff time is taken up with medication and greater protection is afforded to service users since the secondary dispensing of medication has stopped. Some previous requirements and recommendations have been addressed. And the registered manager has begun working towards the Registered Manager’s Award, which will support him in his management role. Improvements have been made regarding hygiene standards so that service users are protected from the potential risk of infection. Service users reported that the home is fresh and clean. A quality assurance questionnaire has been used to obtain service users’ views about the home, the overall findings of which were positive. Some areas for Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 7 improvement were identified and the registered person has developed an action plan to address these. 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 House DS0000026273.V301083.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 House DS0000026273.V301083.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, 6 Service users’ needs are assessed prior to admission to ensure that the home can meet their needs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Holme House does not provide intermediate care. From discussion and records it’s evident that service users’ needs are assessed before they move into the home and confirmation of this, in the form of a contract, is provided. Two service users confirmed they had received a contract and one reported having stayed at the home for a while to see if she liked it. On the first day of this site visit, the registered manager and a senior member of staff also visited a prospective service user to carry out a preadmission assessment. Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 10 Mixed responses were received from four health and social care professionals about whether the home’s management/staff make appropriate decisions when they can no longer manage service users’ care needs. Four GPs felt appropriate decisions were taken. The registered manager explained that reassessments are made when a service user’s needs change and that two service users whose needs could no longer be met at Holme House had recently moved to another service. A recent reassessment of one service user’s needs was also on file. It would be beneficial, as part of the home’s quality assurance process, for GPs and other health and social care professionals, as stakeholders, to be invited to give their views about the care provided at the home. This could also benefit communication between the service provider and health and social care professionals. Holme House DS0000026273.V301083.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, 10 Service users have a care plan which sets out their needs. These are not always up to date or complete. Service users’ health care needs are met. Medication is generally dealt with appropriately. Service users are treated respectfully and their privacy maintained. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans and associated documentation for four service users were inspected. There was evidence of care plan reviews. Risk assessments were available and there was evidence of review, but one assessment relating to pressure areas had not been reviewed for some time even though a risk was present. Risk assessments should be reviewed alongside the care plan on a monthly basis. A recommendation is made in this report. Care plans had not been signed by the service user or their representative in all cases. However, where one relative did not wish to be involved, this was Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 12 recorded. A recommendation is made for service users, where able, or their representative to sign care plans as evidence of their involvement and agreement with the plan. It was evident that following the additional visit in January 2006, action had been taken to address shortfalls in care planning. Generally, care plans contained a good level of detail and instruction for staff. There was some inconsistency in recording, as not all documents had been fully completed and not all identified needs had a plan of care, for example, in relation to eating and drinking and challenging behaviour, when the assessment indicated a risk. Also, some areas of care planning would benefit from greater detail, for example, the size of sling to be used during movement and handling; the type of continence pad to be used and the action staff should take if it’s found that a service user, at risk of poor nutrition, loses weight. A requirement is made for all assessed and identified needs to have a detailed plan of care. Daily records generally reflected the plan of care. There were reporting omissions on one service user’s record. It was evident from discussion and records that service users have access to healthcare professionals so that their healthcare needs are met. Where appropriate, pressure-relieving equipment had been provided and specialist advice included in the plan of care. Seven healthcare professionals reported that any advice given is incorporated into the service user plan; one said it usually was. Service users who commented said that they always received the medical support they needed. And a relative stated that “Family are notified as soon as there is a problem and updated when a doctor has been”. Seven relatives and eight health and social care professionals indicated satisfaction with the overall care provided. One relative commented that “I have been very pleased with the care given to my (relative) at Holme House”. It’s positive to note improvements have been made to the operation of the medication system. It’s important for medication records to be clear and upto-date so that stock can be easily audited and so that medication information is readily available to staff. The registered manager was also advised to consult with a pharmacist regarding the safe disposal of spoiled medication as current practice, as described by staff, is not satisfactory. A requirement and recommendation regarding medications has been made in this report. It was evident from comments received and observation that service users’ privacy is respected. Holme House DS0000026273.V301083.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, 15 Service users maintain contact with family and friends and some, who are able, access community based facilities. Service users are helped to exercise choice. Generally, service users are provided with activities that they enjoy. The food provided is generally enjoyed by service users. . Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Information in assessment and care planning documents generally reflected service users’ preferences, but there were gaps in recording some details, for example, whether a service user wished to practice their religion and if so, how this was to be accommodated. There were mixed responses from service user surveys, a relative and a social care professional regarding the provision of activities at the home. Three service user surveys noted that activities were ‘always’, ‘sometimes’ and ‘usually’ arranged that they could take part in. A relative thought there should be more ‘entertainment or things going on’. And a social care professional reported that there was a ’lack of mental stimulation’. However, not all service users wish to take part in communal activities. Some service users are Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 14 mentally and physically frail and the registered manager explained that it was sometimes difficult to motivate some service users, particularly regarding activities outside the home, but that activities such as entertainers and reminiscence were well received. On the second day of this visit some service users clearly enjoyed taking part in a sing-a-long with an entertainer who was visiting the home. Other service users spoke of enjoying motivation exercises and listening to piano music. It was reported that activities such as bingo and dominoes are provided as well as visits to church services, the local pub, coffee shop and library. A range of music is also available to suit different tastes. It would be useful for regular consultation to take place with service users about the range and frequency of activities provided by the home. A recommendation about this is made in this report. Service users were able to receive visitors in private. And a visitor said that staff were welcoming. Service users are supported to make decisions about their life in the home and some preferences regarding lifestyle were seen within care planning documents, for example, times of rising and going to bed, food and personal care preferences. Service users can take meals in their private accommodation if they prefer or require this. There are two dining areas accessible to service users, although the upper dining area is mainly used by service users who use wheelchairs. Meals are prepared in the kitchen and served by staff from a hot food cabinet in the ground floor dining area. The mid-day meal was freshly prepared and looked appetising. Generally, service users made positive comments about the food provided. It would be beneficial, as discussed with the registered manager, for him to make observations during mealtimes and to consider mealtime arrangements, so that service users do not spend an excessive amount of time waiting to be served; so that staff sit with, rather than stand over, service users when giving assistance to eat and so that service users are enabled to manage their food and are not given their main meal and hot pudding at the same time. A recommendation about this is made within this report. A second cook is in the process of being recruited. The cook on duty explained that she was in the process of drawing up new menus. New menus should include the full choice of food, including the vegetables and puddings to be provided. A recommendation is made within this report. New documentation was on the point of being introduced, which should support record keeping in the area of food provision and storage. As discussed with the cook and the registered manager, where service users require a liquidised diet, care should be taken to present it attractively, for example, by keeping different types and Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 15 colours of food separate in order to maintain appetite, rather than blending it all together. A recommendation is made in this report. Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 16 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, 18 Complaints received by the home are addressed. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home’s complaints procedure was displayed in the entrance area. Neither the home nor the Commission have received a complaint in the last 12 months. The last recorded complaint received by the home was in July 2004. Not all relatives and service users surveyed were aware of how to make a complaint. However, six of the seven relatives who returned surveys reported never having had to make a complaint. A service user who said she had no complaints also said she was happy at the home. It was evident from records and discussion with staff and management that staff receive training in adult protection. CRB (Criminal Record Bureau) and POVA (Protection of Vulnerable Adults) checks are carried out on prospective employees to ensure they are safe to work with vulnerable adults. Holme House DS0000026273.V301083.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, 26 Generally, the environment is safe, well maintained, clean and pleasant. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The floor covering to a ground floor toilet requires replacing as it is lifting and stained in parts. The toilet walls should also be redecorated as the wallpaper is ripped in parts. A previous recommendation regarding this is carried forward. Redecoration is continuing at the home and work is to a good standard. The décor in communal areas is bright and the communal lounges and dining rooms receive good natural light. Aids and equipment are provided to meet the needs of service users. Service users who commented said they were satisfied with their bedroom accommodation. Following a visit by an Environmental Health Officer in April 2006, action has been taken to clean the kitchen fly screens. However, the condition of the fly Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 18 screens should be monitored and could usefully be included as part of the kitchen cleaning schedule. The basement houses the laundry and also acts as a storage area. Duvets were being stored on open shelving together with some flammable paint, which increases the fire loading to the basement. As discussed with the registered manager, flammable items must be stored appropriately to maintain fire safety. A requirement about this is made within this report. An audit of the home by an infection control specialist in February 2006 identified a number of areas for improvement. The registered person must act on the advice contained within the infection control audit report provided to him, so that good hygiene practices are promoted throughout the home. A requirement about this is made in this report. At the time of the site visit, the home was odour free and communal areas and those bedrooms seen were clean and tidy. Service users also reported that the home was always fresh and clean. Staff reported that systems are in place for reporting any maintenance works. Holme House DS0000026273.V301083.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, 30 Generally, sufficient numbers of trained staff were available to meet the needs of current service users. Service users are generally supported and protected by the home’s recruitment practices. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There were mixed responses from service users and relatives regarding the availability and numbers of staff on duty. The majority of relatives reported that staffing levels were sufficient. Two of the three service users who returned surveys reported that staff were usually available and that they usually received the care and support they needed. The vast majority of professional surveys noted that a senior member of staff was always available to confer with. Staffing levels are four carers plus a senior carer on the morning shift and three carers plus a senior carer on the afternoon shift. The manager’s hours are in addition to this. There are two wakeful night staff and an on-call system is in operation. Staffing levels meet the minimum levels set by the previous regulatory authority. However, staffing is an area that should be kept under Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 20 review taking into account any changes in service users’ dependency levels and the staffing arrangements in place over meal times. The recruitment and training records for three members of staff were inspected. There were some gaps in recording required information such as the number of hours employed and the position held and a recommendation is made about this but, generally, all the required pre-employment information was available. As discussed with the registered manager, where attempts have been made to obtain a second reference and there are difficulties in obtaining this, there should be recorded evidence of the action taken by the registered person to ensure that the person is suitable to work at the home. A recommendation about this is made within the report. From records and discussion with staff it was evident that recommended and mandatory training, including induction training, is available. Not all staff currently employed have received all mandatory training, for example, food hygiene, first aid and movement and handling. From discussion with management and written information provided, action is being taken to address this. Until all staff currently employed have received all mandatory training, a requirement is made in this report. NVQ (National Vocational Qualification) training is ongoing and some staff have achieved or are working towards the level 2 award or equivalent. Fifty per cent of care staff do not yet hold an NVQ level 2, or equivalent qualification. A requirement and recommendation about staff training is made in this report. Holme House DS0000026273.V301083.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, 35, 36, 38 Progress has been made regarding the management of the home. Service users’ views have been sought about the care services provided so that the home is run in their best interests. Service users’ monies are safeguarded by the home. Staff do not receive formal supervision, but informal supervision is in place. Action is taken to promote service users’ health, safety and welfare. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Mr Jeremy Martin is the registered provider and manager of Holme House. He has over seventeen years’ experience of working with this particular service user group. It is positive to note in response to previous requirements Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 22 regarding management training that Mr Martin is now working towards the Registered Managers Award. Improvements have also been made to the overall management of the home and to addressing some previous requirements and recommendations. It is important for this progress to continue and for standards to be maintained. A service user and a relative said that Mr Martin was approachable. Staff felt supported in their work. A survey to obtain service users’ views of the home was sent out at the beginning of the year. The overall findings of the survey were positive and where areas for improvement were identified, for example, regarding the laundry system and provision of information about the home, an action plan has been developed. In accordance with the regulations, a copy of the report must be supplied to the Commission and a requirement about this is made in this report. Monthly reports on the conduct of the care home are required to be carried out under legislation governing care homes for older people. Guidance on how this can be achieved by the registered provider/manager of Holme House was given to him during the site visit. These reports can also be used as part of the home’s quality assurance process. A requirement is made for a copy of the monthly reports to be supplied to the Commission. The home safeguards service users’ monies, a sample of which were audited and reconciled with the records held. As discussed with the registered manager, the home’s policy and procedure on the management of service users’ monies and financial affairs should be amended in line with the National Minimum Standards for Older People (NMS). A recommendation about this is made within this report. Although there was evidence that some staff supervision takes place, staff, including senior carers, do not receive formal supervision six times a year as recommended in the NMS. Formal staff supervision should be provided to all staff and records maintained. A recommendation is made within this report. As noted elsewhere in the body of the report action is required in relation to infection control and staff training. Records show that staff are involved in fire drills and receiving fire safety training. Health and safety records also show that fire safety and other equipment used at the home are serviced as required to promote the health and safety of service users, staff and visitors. Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(a) (c) Requirement Service users or their representative must be consulted about the service user’s plan of care. (Timescales of 08.07.05 and 05.12.05 not fully met). The service user’s plan must include all assessed and identified health personal and social care needs. (Timescale of 05.12.05 not fully met.) Care plans must be detailed. Accurate and up-to-date medication records must be kept. (Timescale of 05.12.05 not fully met.) Medication must be disposed of safely. The registered person must ensure that the home meets the requirements of the fire authority. Therefore, flammable items must be stored appropriately. (Timescale of 12.12.05 not fully met.) Satisfactory standards of hygiene must be promoted throughout the home to minimise the risk of infection. Therefore, the registered person DS0000026273.V301083.R01.S.doc Timescale for action 28/08/06 2. OP7 15(1) 28/08/06 3. OP9 13(3) 28/08/06 4. OP19 23(4) 28/07/06 5. OP26 16(2)(j) 28/08/06 Holme House Version 5.2 Page 25 6. OP30 13(4) 18(1)(c)(i ) 24 7. OP33 8. OP33 26 must take action to address the issues identified by the Health Protection Nurse in the audit report dated 02.02.06. An action plan with timescales for addressing these must be supplied to the Commission by the date opposite. All staff currently employed who 04/12/06 have not received mandatory training in first aid, movement and handling and food hygiene must do so. The registered person must 28/08/08 supply to the Commission and make available to service users a report in respect of the quality review recently undertaken. Monthly reports regarding the 29/09/06 conduct of the care home must be completed and a copy of any report supplied to the Commission. 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 OP2 Good Practice Recommendations Each service user should have a written statement of terms and conditions with the home. (Not assessed on this occasion). Care plans should be updated to reflect changed needs. Where a risk is identified, for example, falls, a care plan should be produced and detail how the risk is to be managed. There should be no gaps in the daily reporting of service users’ health and welfare. Daily reports should be written in sufficient detail as to whether or not the care plan is DS0000026273.V301083.R01.S.doc Version 5.2 Page 26 2. 3. OP7 OP7 4. OP7 Holme House meeting the outcomes for service users. 5. OP8 Service users should be assessed against the risk of poor nutrition and the assessment reviewed monthly. Where a risk is identified, a care plan should be put in place and detail how the risk is to be managed. The home’s medication policy should be fully implemented. And a lockable medicines fridge should be provided. The home’s complaints procedure should be clearly displayed at the home. All staff who have not yet done so should receive training in adult protection. The home’s adult protection risk assessment and policies and procedures relating to adult protection and whistle blowing should be reviewed to ensure they are up to date and accurate. Disused furniture, which was being stored at the rear of the property, should be removed. The smoking room should be cleaned. The toilet flooring identified during previous inspections should be replaced. (Standard not assessed on this occasion). The wall-mounted cupboards in service users’ bedrooms should be re-located or removed to promote health and safety. (Not assessed on this occasion). An audit of bedding should be undertaken to identify items that need replacing. Adequate temperatures should be maintained at all times in the ground floor lounge so that service users are not cold. The registered manager should supply the Commission with a revised action plan for ensuring safe water temperatures and preventing risks from scalding. (Not assessed on this occasion, but an action plan has not been received by the Commission). 6. 7. 8. 9. OP9 OP16 OP18 OP18 10. 11. 12. OP19 OP19 OP21 13. OP24 14. 15. OP24 OP25 16. OP25 Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 27 17. OP26 The registered person should consult with a Health Protection Infection Control Advisor regarding the promotion of good infection control practices. The post of training co-ordinator should be recruited to. The registered manager should provide the Commission with an action plan detailing how 50 of staff are to achieve NVQ level 2 qualification or equivalent by 31.12.05. (Not assessed on this occasion, but to date, an action plan has not been provided). The registered manager should obtain an NVQ level 4 in care and management or equivalent by 31.12.05. The views of friends and of stakeholders in the community (e.g. health and social care professionals), should be sought as part of the home’s quality review. The registered person should provide the Commission for Social Care Inspection (CSCI) with an action plan that identifies how requirements identified in CSCI inspection reports are to be progressed within agreed timescales. The registered person should ensure that the home operates in accordance with the policy on service users’ financial interests and records should reflect that this is happening. Care staff should receive formal supervision at least 6 times a year. The staffing rota should include the employee’s surname and designation together with the length of the shift being worked so that it is clear to anyone inspecting the rota what the start and end time of any one shift is. 18. 19. OP27 OP28 20. 21. OP31 OP33 22. OP33 23. OP35 24. 25. OP36 OP37 Holme House DS0000026273.V301083.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 House DS0000026273.V301083.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. 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