Inspection on 24/10/05 for Holme House

This inspection was carried out on 24th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 House 08/05/09

Holme House 22/05/08

Holme House 30/05/07

Holme House 19/06/06

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 24th October 2005 09:30 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.V260959.R01.S.doc Version 5.0 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.V260959.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Holme House Address Oxford Road Gomersal Cleckheaton West Yorkshire BD19 4LA 01274 862021 01274 871702 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.V260959.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user under 65 years of age - DE category 7th June 2005 Date of last inspection Brief Description of the Service: Home House is a care home registered to provide personal care and accommodation for up to forty older people. It is situated in the Gomersal area of Kirklees fairly close to Birkenshaw, Birstall and the M62. The original property has been extended and modernised for its current use. Some of the property’s original features have been retained adding to its homely feeling. There are large 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. There is ramped access to the front door of the home. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection of Holme House on 24.10.05. The inspection started at 09.45 and ended at 17.40. At the time of the inspection there were 38 service users in residence. The following inspection methods were used: discussion was held with service users, visitors, management and staff. A sample of records were inspected, including: care plans, risk assessments, medication, service users’ monies, staff recruitment and training records, staffing rota, some policies and procedures. A tour of the building was made. The inspectors would like to thank service users, visitors, staff and management for their time and hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Some redecoration of communal areas has taken place and as noted above, these are of a good quality. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 6 Some staff have received training in adult protection and staff demonstrated a good general understanding of adult protection and the relevant action to take were abuse to be suspected or observed. 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 Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 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.V260959.R01.S.doc Version 5.0 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): EVIDENCE: None of these standards were assessed at this inspection. However, the registered person explained that the home’s certificate of registration had been removed during redecoration works. The certificate must be clearly displayed at the home. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Not all service users’ health, personal and social care needs are set out in an individual plan of care. Healthcare professionals are involved in the care of service users. Service users are not protected by the home’s policy and practices for dealing with medicines. EVIDENCE: Individual plans of care were available. On those care plans sampled there was evidence of reviews but the plans had not always been updated to reflect changed needs. Care plans need to be more detailed and specific. Discussion with a member of staff indicated that a service user could manage some personal care tasks, but this information was not included in the plan of care. It is important to include the service user’s strengths in the care plan, as well as their needs, so that their ability to be self-managing is not overlooked. Discussion with staff suggested that some needs were being addressed even though care plans lacked detail. Risk assessments were available, but not all identified risks had a corresponding plan of care. A service user at risk of falls was to be referred to Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 11 a physiotherapist but there was no evidence of this and a care plan regarding the service user’s mobility was not available. There was evidence that service users’ weight is recorded. However, an entry in one service user’s file noted that a relative had expressed concern about the service user’s weight loss but there was no evidence that the service user’s weight was being monitored. When weight loss is evident and the person is not on a weight reducing diet, appropriate action should be taken to address this. There was no evidence that action had been taken where service users were losing weight. Nutritional risk assessments should also be completed. This is not happening for all service users at present. There were gaps in daily reporting. Those seen did not give sufficient detail as to whether or not the care plan is meeting the outcomes for service users. Care planning should involve the service user and/or their representative, but there was little evidence that this was happening. It is clear that health care professionals such as GPs, chiropodists, dentist and community psychiatric nurses are involved with service users. At the last inspection there were issues regarding the management and administration of medication. Issues were again identified. Medication for the week of the inspection had not been entered into stock and the stock balance of ‘as required’ medication had not been brought forward. Secondary dispensing of medication is still taking place. Not all controlled drugs (CD) are being double signed when administered or recorded in the controlled drugs book. The home’s policy and procedure, which states that a lockable medicines fridge is provided, was overdue for review. A lockable fridge is not available at the home although the registered person said that one would be provided. It’s important that the registered person ensures that policies and procedures are being adhered to. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Social activities are provided for service users. They are able to maintain contact with family and friends. Service users are supported to exercise choice. EVIDENCE: Social care plans have been introduced, but need development to ensure that service users’ preferences are recorded. Pop music was playing in the central area of the home for a period of time, however, staff did change it to music more suited to the age of the people living at the home. A choice of music was available. A service user said she enjoyed the singers and entertainers who visit the home. Reminiscence boxes are borrowed on a monthly basis from the local coal-mining museum and staff go through these with service users who were said to enjoy the activity. A religious service is held at the home and service users said they could also go out to a local place of worship. Owing to mental or physical frailty, some service users are limited in the choices they are able to make about their lives. However, food and drink choices were offered to service users. And service users were observed to take breakfast at varying times throughout the morning. A service user said there was choice in times of rising and going to bed. Mobile service users were seen to move freely around the home. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 13 Service users are able to maintain contact with family and friends and visits can be made in private. A visitor said that she was made welcome by staff at the home. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Processes are in place to protect service users from the potential risk of abuse. EVIDENCE: Staff spoken to had a good general understanding of adult protection issues and the relevant action to take were they to see or suspect abuse. Adult protection training is ongoing but not all staff have received this yet. The home’s adult protection risk assessment and policies and procedures relating to adult protection and whistle blowing need reviewing to ensure they are up to date and accurate. Although standard 16 was not assessed it was noticed during the inspection that the home’s complaints procedure was not on display. This should be addressed. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26 Improvements are being made to the environment, but further work is necessary. Poor practice regarding fire safety has the potential to place service users, staff and visitors at risk. Generally, the home was clean and tidy although some poor hygiene practices have the potential to place service users and staff at risk. EVIDENCE: Some redecoration of the home has taken place and is to a good standard. A programme of redecoration is ongoing and corridors are currently being redecorated. Original features of the period building have been maintained and add to the homely environment. The large ground floor lounge is light and airy. However, on the day of the inspection, some service users complained that the room was cold. The lounge did heat up as the day progressed, but adequate temperatures should be maintained at all times. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 16 There are mature gardens to the front and rear of the property, which allow service users access to sunlight. Disused furniture, which was being stored at the rear of the property, should be removed. Poor practice regarding fire safety was evident. Paint was being stored in a disused bathroom with a ladder giving access to the roof space through a trap door. This presented a risk to service users. The registered person addressed this when it was drawn to his attention. He said that fire detection was in place in the roof space. Fire doors were still being wedged open despite previous requirements to stop this practice. The registered person said that an audit of all doors requiring hold open devices had been completed and devices were being sourced and would be put in place. He also explained that a smoke detector to a corridor ceiling had been covered over as dust generated by workmen was setting off the fire alarm. The registered person must ensure that the home meets the requirements of the fire authority so that the health and safety of service users and those working at and visiting the premises are not put at risk. A smoking room is available, but the room was dirty and the carpet had burn marks. An Environmental Health Officer visited the home in April this year. Recommendations were made and were to be addressed within a three-month timescale. Following this inspection, written confirmation has been provided to the commission that the Environmental Health Officer is satisfied with the action taken to address the recommendations within her report. Standard 25 was only assessed to follow up a previous requirement regarding water temperatures. A water temperature sample gave a reading within acceptable limits. Generally, the home was clean and tidy. However, there were urine odours to some bedrooms, a toilet and the passenger lift. There was also evidence of poor hygiene practices, for example, the use of communal hygiene equipment (see Standard 38) and dirty laundry being left on a bathroom floor. Inappropriate commode liners were being used which, apart from being unsightly, have the potential to increase the risk of infection. Some beds had been made up, even though the bedding was soiled. Such practices are not acceptable and increase the risk of infection. Some beds had been made up with items of damp bedding. An audit of bedding should be carried out as some bedding was worn and needs replacing. The laundry area was disorganised and was not being kept clean. Appropriate hand-washing facilities are not in place in this area and must be installed. The registered person said that sluicing facilities were in place in the laundry. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29 Sufficient staff were on duty to meet the needs of current service users. Service users are not supported and protected by the home’s recruitment practices. EVIDENCE: 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. An on-call system is in operation. Two senior carers whose duties also include management of the medication system, care planning, staff recruitment and day-to-day staff supervision as well as some staff training, assist the registered manager. The home used to employ a training co-ordinator but to date, the vacant post has not been filled. A sample of five staff records were inspected. It was evident that some staff are being employed to work at the home before all required checks are undertaken or complete. A similar issue was identified at the previous inspection. Such poor practice does not afford service users proper protection. The registered person is required to undertake an audit of all those employed to work at the home and provide a copy to the Commission to evidence that required checks are carried out in a satisfactory manner. Although an induction programme is in place at the home, it was evident that not all new staff have received induction training. It is a requirement of this Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 18 report that new staff receive accredited induction training to National Training Organisation standards and evidence of this must be available for inspection. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 37 The registered manager is not fully discharging his responsibilities. The home’s quality assurance review is not complete and does not provide for consultation with service users, so it is not possible to state that the home is run in their best interests. Service users’ monies are safeguarded. Staff are not being appropriately supervised. Although Standard 38 was not fully assessed, there was some evidence to suggest that the health, safety and welfare of service and staff is not being adequately promoted and protected. EVIDENCE: The registered manager, Mr Jeremy Martin, is also the registered provider. He has over seventeen years’ experience of working with this particular service user group. Although Mr Martin has recently received training in adult Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 20 protection, he has not, as yet, taken steps to obtain a qualification at level 4 NVQ in management and care or equivalent. As discussed with him at the time of the inspection, he needs to make progress towards achieving this award. This will help to ensure that his practice and knowledge is up to date. Owing to shortfalls identified in other parts of this report, it is evident that Mr Martin is not running and managing the home to the standard required by the regulations and national minimum standards for older people. Where, in the past, the Commission has considered enforcement action with regard to staff recruitment, standards have been raised, but the findings of this and the previous inspection demonstrate that recruitment standards are not being maintained and service users are being placed at potential risk. Failure to improve and maintain standards will bring into question the fitness of the registered manager. Staff spoken to felt that Mr Martin was approachable and was available for advice. No further progress appears to have been made regarding the home’s quality audit. Staff spoken to were not aware that any consultation was taking place nor of any quality review report. The registered person must address this shortfall and as previously required service users must be involved in the consultation process. It is recommended that other stakeholders are also consulted as part of the quality review process. The home safeguards service users’ monies. A sample of service users monies were audited and reconciled with the records held. The home’s policy states that staff will ensure that service users retain effective control of their monies except where they state that they do not wish to or they lack capacity. Discussion with staff indicated that this is not risk assessed and that the home has always looked after service users’ monies. The home should operate in accordance with its policy and records should reflect this. Although standard 36 was not fully assessed it was evident from discussion with staff that they are not receiving formal supervision. A member of staff who used to carry out formal staff supervision has left the home and has not yet been replaced. Standard 37 was only assessed with regard to the staff rota. The manager’s working hours have not been included as previously required. 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. Although Standard 38 was not fully assessed, it was evident that a review of the home’s fire risk assessment was overdue and this should be addressed. Staff fire safety training was held recently, but some staff have not received Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 21 this training since 2004. This is not acceptable and must be addressed. Fire safety training records do not provide sufficient detail regarding the training given to staff and this must be addressed. As noted under Standard 26 above, poor hygiene practices were evident. A requirement was made following the last inspection for the use of communal soap and washing equipment to be discontinued. This has not happened. It is also a requirement of this report that the cook currently employed, receives refresher food hygiene training. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 22 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X 3 1 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 1 2 1 Holme House DS0000026273.V260959.R01.S.doc Version 5.0 Page 23 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 2 Standard OP1 OP3 Regulation CSA 2000 Requirement Timescale for action 21/11/05 21/11/05 3 OP7 4 5 OP7 OP9 6 OP19 The certificate of registration must be affixed in a conspicuous place in the home. 14(1)(d) Following assessment, the service provider must confirm in writing to the service user that their health and welfare needs can be met at the home. (Not assessed on this occasion). 15(2)(a)(c Service users or their ) representative must be consulted about the service user’s plan of care. (Timescale of 08.07.05 not met). 15(1) The service user’s plan must include all identified health, personal and social care needs. 13(3) Accurate medication records must be kept. Stock must reconcile with records held. The secondary dispensing of medication must stop. (Timescale of 08.07.05 not met). 23(4)(c)(i The practice of wedging open fire ) doors must stop. Suitable hold open devices must be installed which meet fire safety requirements. (Timescale of 08.07.05 not met). DS0000026273.V260959.R01.S.doc 05/12/05 05/12/05 05/12/05 21/11/05 Holme House Version 5.0 Page 24 7 OP19 23(4) 8 9 OP24 OP26 16(2)(c) 16(2)(j) 10 OP26 16(2)(j) 11 OP29 19(1)(b)(i ) 12 OP29 19(1) 13 OP29 18(1)(c)(i ) 9 14 OP31 15 OP33 24 The registered person must ensure that the home meets the requirements of the fire authority. Worn bedding must be replaced. Satisfactory standards of hygiene must be maintained throughout the home to minimise the risk of infection. Areas of poor practice detailed in the body of this report must be addressed. To promote good hygiene practices, appropriate handwashing facilities must be installed in the laundry area. Required checks must be carried out on employees before they start to work at the home. (Timescale of 08.06.05 not fully met). The registered person is required to undertake a detailed audit of employment records for all staff working at the home to ascertain whether all required information is available. A copy of the audit must be supplied to the Commission. New staff must receive structured induction training. And evidence of this must be available for inspection. The registered manager must take action to address identified shortfalls. And the home must be managed and run to the required standard. (Timescale of 08.07.05 not met). The registered person must ensure that consultation takes place with service users as part of the quality assurance process and supply to the Commission and make available to service users a report in respect of the quality review. (Timescale of 07.10.05 not met). DS0000026273.V260959.R01.S.doc 12/12/05 19/12/05 28/11/05 12/12/05 21/11/05 21/11/05 21/11/05 12/12/05 31/12/05 Holme House Version 5.0 Page 25 16 OP37 17(2) Schedule 4 24(4)(d) 17 OP38 18 OP38 13(3) 19 OP38 18(1)(c)(i ) The registered manager’s working hours must be included on the staffing rota. (Timescale of 08.07.05 not met). All staff working at the home must receive fire training twice each year from a competent person. And detailed training records must be kept. The use of communal soap and washing equipment must stop. Such equipment must be personal to the service user to minimise the risk of cross infection. (Timescale of 08.07.05 not met). The cook currently employed at the care home must receive refresher food hygiene training. 21/11/05 12/12/05 21/11/05 28/02/06 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 2 3 4 Refer to Standard OP2 OP7 OP7 OP7 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 meeting the outcomes for service users. 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. DS0000026273.V260959.R01.S.doc Version 5.0 Page 26 5 OP8 6 OP9 Holme House 7 8 9 OP16 OP18 OP18 10 11 12 13 14 15 16 OP19 OP19 OP21 OP24 OP24 OP25 OP25 17 18 19 OP26 OP27 OP28 20 21 22 OP31 OP33 OP33 23 OP35 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). 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’ DS0000026273.V260959.R01.S.doc Version 5.0 Page 27 Holme House 24 25 OP36 OP37 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. Holme House DS0000026273.V260959.R01.S.doc Version 5.0 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.V260959.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!