Inspection on 08/05/09 for Holme House

This inspection was carried out on 8th May 2009.

CQC 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 CQC 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 22/05/08

Holme House 30/05/07

Holme House 19/06/06

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Holme House Oxford Road Gomersal Cleckheaton West Yorkshire BD19 4LA Lead Inspector Tony Brindle Key Unannounced Inspection 8th May 2009 09:00 DS0000026273.V375435.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Holme House DS0000026273.V375435.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 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 Michelle Rathbone Care Home 54 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (54) of places Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category, Code OP 2. Dementia, Code DE The maximum number of service users who can be accommodated is: 54 22nd May 2008 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 weekly fees in May 2009 range from £335.24 to £380.00 per week. Additional charges are made for hairdressing, newspapers and toiletries. Holme House is a newly, purpose build building. The facilities include: • large bathrooms with modern equipment to support people with physical disabilities • ensuite bedrooms with TV and DVD players fitted • good quality bedroom furniture • large spacious lounges and small areas for private use • an excellent kitchen facility • small kitchen facilities in the lounges • an excellent laundry facility with laundry shoots that directs laundry to the laundry facility therefore there is no risk of soiled items being taken through communal areas • a pleasant patio area that is used by the people living at the home • a main office with offices for staff and private consultation if required movement sensor lights on corridors and bathrooms. Information about the home and the latest Commission report are available from the home. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The outcomes for people using this service have been rated as 1 Stars – Adequate. This was an unannounced visit to the home. We spent some time having a look at the paperwork at the home, and we talked to people who live at the home, had a look round the home, checked the medication and money, and talked to the staff. The paperwork we looked at included peoples care plans and assessments, some staff personnel and training files, the medication, health and safety records, the menus and kitchen records, and the daily records made by the staff about the activities people had been involved in during the day. We would like to take the opportunity to thank the people living at the home, the registered manager and the staff for their hospitality and patient cooperation throughout the inspection. Prior to this visit, we received a number of telephone calls from a complainant. They stated that their relative who lived at Holme House was feeling unsafe due to the fact that 2 people had been admitted to the home that had dementia care issues and challenging behaviour, one of which had attacked their relative. We made enquires with the registered manager and owner of the home who stated that 2 recent admissions had taken place, and that they were discussing with the local authority the appropriateness of these admissions, with a view to finding alternative placements. Evidence relating to these admissions is contained within this report. Holme House now operates from a purpose built building that was registered for use in January 2009. This visit was the first inspection visit to the home since it opened at its new location. There has been no change to the manager of the home or ownership of the home. The registered manager and staff continue to keep us informed of incidents and developments within the service. What the service does well: There are good management systems in place that enable the manager to monitor, audit and review the care and support being given at Holme House. Good quality information contained within care plans and risk assessments ensures that the staff have the right information to met people’s needs. People benefit from a range of activities based on their interests, and people enjoy a wholesome, varied diet based on their individual needs and tastes. There are usual good systems for protecting and safeguarding people. The home has an appropriate complaints procedure that people are aware of and know how to use. The living environment, layout of the building and equipment on offer to people are all of a high standard and people are very satisfied with the facilities on offer. A well trained and dedicated staff team care and support people in a positive manner. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 7 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.V375435.R01.S.doc Version 5.2 Page 8 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Failures in the systems for thoroughly assessing the needs of new people admitted into the home, has resulted in inappropriate admissions being made in recent weeks, and people’s needs not being met. EVIDENCE: The registered manager described the admission process in detail. She explained that either she or a member of the management team visits each prospective new person to assess their needs. The registered manager explained that she also obtains any available information from a person’s social worker if they have one, such as a community care assessment or other Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 9 assessment information. If a prospective new person is privately funded, the registered manager said that most of the information is gained through liaison with the person themselves and or their family members. Once all the information has been obtained about a person’s needs, then a decision is made about whether the service can meet the person’s needs and either their social worker or the person themselves is told about the decision. On checking the records of 2 people who had recently moved into the home, it was clear that despite a thorough assessment of the people’s needs being undertaken, the decision to admit the people into the home was inappropriate. Information from the Local Authority had not been sent the home in good time prior to the admission. This led to the 2 people being inappropriately placed and admitted into the home. It was clear from reading the assessment information relating to these people that their overriding care needs related to issues with dementia care and problems with challenging behaviour, and not general nursing care. The registered manager agreed with this point. The home is registered for general nursing care, and one named person with dementia. The home is not registered to cater for people with dementia care needs. The registered manager explained that the systems relating to admissions into the home have been reviewed. Admissions will now not take place until all the information required by the registered manager has been received. This will include (if available) all relevant assessments, care plans and reviews from the local authority and primary care trust. She added that once a decision has been made that the service can meet the needs of a new person, then a letter will be sent out to them or their social worker confirming this. The registered manager added that once a person has moved into the home, then the service will continue to assess the person for 48 hours to ensure that they have all the right information about the person to ensure their needs can be met. She added that if there are any difficulties, or there is a suspicion that the placement is inappropriate (i.e. out of registration category) then the social work team will be contacted and discussions started with reference to the need for an alternative placement. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good quality information contained within care plans and risk assessments ensures that the staff have the right information to met people’s needs, however, shortfalls in some medications practices, and a delay in rectifying medication issues overshadowed the good care planning practices. EVIDENCE: The registered manager showed us the care plan files of 4 people living at the home. She was able to explain the care planning process in great detail, which she said includes making sure that the staff learn what is important to the person in everyday life so that they can be supported to live a fulfilling life. She added that the staff involved in the care planning process, find out what the health and safety risks are to each person by talking to them and their families, and by undertaking a risk assessment, which is documented. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 11 Information contained within the care plan files confirmed what the registered manager had spoken about. She added that wherever possible, the person themselves, and or their family members (if appropriate) are involved in the care planning process. Again this was supported by way of information contained within the care plans with peoples signatures being seen on various documents. People living said that the staff ask them about what they like to do, about what their interests are and about how they like to be supported to undertake certain activities such as washing, dressing, shopping and socializing. Staff at the home confirmed that they are involved in care planning, and were able to speak about the process in a manner that indicated that they saw it as an important part of what they do, and not just a task to be completed. We looked at the daily records which were found to contain information about what people had been doing during the day and night. The information was seen to be factual and non-judge-mental, and when decisions had been made to participate in different activities, the reasons for this had been recorded. The registered manager explained that for some people, decision making can be difficult due to their level of cognitive ability, adding that when decisions are made on a persons behalf, to engage in a social activity for example, then the staff always ensure that good records are kept so that the reasons why and when decisions are made by others can be clearly demonstrated. Information contained within the daily records confirmed this. The registered manager explained that personal supported is always provided to people in private, and that routines such as the times for going to bed, having baths, meals and other activities are flexible. She added that people are encouraged to choose their own clothes and hairstyle, and where possible peoples appearance reflects their personality. Discussions with people living at the home confirmed this. Observations made on the day of the visit confirmed that staff work with people in a sensitive manner, providing flexible personal support in ways that promote peoples privacy and dignity and where possible their independence. Information contained within peoples care files indicated that peoples health is monitored and any potential complications and problems are identified and dealt with at an early stage, including referral to the appropriate health-care professional. The registered manager explained that people with specific health-care needs are supported to visit a specialist, and if they are unable to make their own appointments, the staff do this on their behalf. This was supported by way of information contained peoples care plans showing when appointment had been made, the outcome, and any action that needs to be taken by the person, or the staff at the home to promote peoples health and wellbeing. Feedback from relatives indicated that they were satisfied with the way in which staff at the home support people with their health-care needs. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 12 A sample of the medications held at the home was looked at and unfortunately some errors were found in the recording. These had previously been identified by the registered manager when she had undertaken an audit of the medication. She explained that she had asked the nursing staff to rectify the issues, but this had not taken place. She explained that she would look into the issues over the weekend and ensure the problems were rectified. The registered manager contacted the Commission at the start of the next week, and explained that actions she had taken to rectify the medications problems, providing documentary evidence to support her actions. The staff training records show that staff have had training in the use and medication. It was explained to the registered manager at the time of the visit that the issues identified with medication may have an impact on the quality rating of the service. Holme House DS0000026273.V375435.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a range of activities based on their interests, and people enjoy a wholesome, varied diet based on their individual needs and tastes. EVIDENCE: The records show that there are two dedicated activity staff employed at the home who engage in activities with people in both the lounge and in smaller, quieter areas of the home, where individualized activities can and do take place. One person living at the home said that different entertainers come in to the home on a regular basis, and that a holistic therapist visits once a month. They added that local priest and vicars come to visit. All this was supported by way of comments from the staff and information contained within the daily records. The registered manager explained that all the people living at the home are requested to pay £5 a week into an activities fund. The money raised is used to organise transport to and from organized events, and can be used to Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 14 pay for tickets for events. A discussion took place with the registered manager about the safeguards surrounding this fund, and the need to ensure fair access to activities for people who may not want to pay £5 week into a communal fund. The registered manager explained that she would be discussing this issue with the operations director for the company to ensure that clear guidelines, policies and procedures were in place to make sure that the operation of the fund was clear, transparent and free from discrimination. Observation of care practices, and the way people are supported showed that the staff are flexible and attempt to provide a service that is individualized. People living in the home say that are spoken with as to how they would like to spend their time, and how they would like to be cared for. The registered manager explained that the staff help people to get involved in a number of activities such as card games, bingo, chair exercise and craft work. One person who was spoken with explained that they really enjoy the activities and said that they like the variety on offer. Another person who had just returned from an outing with their relative said, “People do get the opportunity to go out for walks, visits to garden centres and sometimes even to the pub.” One visitor at the home said, “The manager and staff have open visiting arrangements,” and one person living at the home said, “I can entertain my family in my own room if I want instead of in the lounge with everybody watching.” The registered manager explained that unless there are legal reasons for people not to do so, they can carry out their own financial, legal and other personal business at a time that suits them. She added that people can decide who should know about, and have access to, their personal business. The records show that people can keep and control their money and their personal belongings, unless their individual circumstances mean that specific legal arrangements have been made. A check of the records and money held by the registered manager found no discrepancies. It is clear from visiting people’s bedrooms, that people are able to have personal possessions in their room. A person at the home said, “The food is of good quality, well presented and suits my needs. “. A look at the menus and food available on the day confirmed what the person had said. The catering manager explained that he can cater for most people’s tastes, and if people do not like what is on the menu on any given day, then every effort will be made to provide a suitable meal for them. He added that there is a system for ensuring that people with specific dietary requirements get the right food and nutrition eg diabetic or high protein. The records relating to this were seen and found to be in good order. Holme House DS0000026273.V375435.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite and service having good systems for protecting and safeguarding people, recent inappropriate admissions of people into the home has led to a physical assault taking place. The home has an appropriate complaints procedure that people are aware of and know how to use. EVIDENCE: The records show that the service has a complaints procedure, which is available within the home, and its content was found to be satisfactory. Three people were spoken with who all said that they understood how to make a complaint and who to go to. The records show that complaints are recorded properly, and the right people are notified and spoken to at the right time. The policies and procedures regarding the safeguarding of people were found to be satisfactory. Within the policy there is clear information as to when incidents need external input and who to refer the incident to. Discussion with 2 staff members showed that they had an awareness of the content of the policy and would know what action to take if an incident took place, and who to refer any incident on to. A group of people living at the home said that they felt safe living at the home. The training records show that the staff team have received training in the area of safeguarding vulnerable adults from abuse. Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 16 The personnel records show that the registered manager has trained as a trainer in adult safeguarding, and has recently attended training on the law surrounding the Mental Capacity Act: a law concerned with decision making, and what to do when people cannot make some decisions, and the safeguards that need to be in place to make sure people’s liberty is not taken away. A discussion took place with the registered manager concerning the fact that the home has a keypad lock on the door, which prevents people leaving the building unless they know the code. It was agreed with the registered manager that she would look into this issue with a view to ensuring that people’s movement in and out of the home was not being unfairly restricted. This would be determined by way of a risk assessment based on people’s mental and physical ability. The records show that following the inappropriate admission of 2 people into the home, 2 incidents of physical abusive took place. These were appropriately reported, and actions taken by the home to safeguard people living at the home. One person was moved out following discussion with the Local Authority. The second remained in the home as alternative placement could not be found. The management of the home eventually took the decision to give the second person seven days notice to leave, which prompted to the Local Authority to increase their efforts so secure an alternative placement. The point was raised with the registered manager that the inappropriate admission of the 2 people did put other people in the home at risk, and that it was of great importance that appropriate assessments of people’s needs took place prior to any admission. The registered manager made the point that there was a considerable delay in obtaining information from the Local Authority about the 2 people, and in one instance an assessment did not arrive until the day of admission. Again we made the point that obtaining the right information before a decision is made to admit a person must be an integral part of the home’s admission procedure. Holme House DS0000026273.V375435.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The living environment, layout of the building and equipment on offer to people are all of a high standard and people are very satisfied with the facilities on offer. EVIDENCE: Holme House is a newly, purpose build building. A look around it found that it has a number of excellent facilities: • large bathrooms with modern equipment to support people with physical disabilities • ensuite bedrooms with TV and DVD players fitted • good quality bedroom furniture Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 18 • • • • • • • large spacious lounges and small areas for private use an excellent kitchen facility small kitchen facilities in the lounges an excellent laundry facility with laundry shoots that directs laundry to the laundry facility therefore there is no risk of soiled items being taken through communal areas a pleasant patio area that is used by the people living at the home a main office with offices for staff and private consultation if required movement sensor lights on corridors and bathrooms The home was found to be clean and tidy. People living at the home said that they found the home pleasant and always clean. Two visitors who were spoken with said that they thought the building was lovely, and that they were really pleased that their relative was able to live there. Holme House DS0000026273.V375435.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A well trained and dedicated staff team care and support people in a positive manner. EVIDENCE: Discussion with people living at the home showed that they have confidence in the staff that care for them. One person said, “The staff really know what they are doing, they’re very kind and patient.” Another person said, “I used to live in a different home, and the staff weren’t as good as those here. I can talk to the staff here about anything, and they’ve always got time to listen.” The records show that the service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. The rota showed that there is a satisfactory mix of qualified and unqualified staff working at the home, appropriate to the assessed needs of the people at the home. Two people living in the home said that they are confident that the staff providing their support and care have been well trained. The records show that a good level of training is offered to the staff team, and that staff without an NVQ II qualification are working towards achieving it. The personnel records show that two written references are obtained before appointing a member of staff, and any gaps in employment records are explored. The registered manager said that new staff are confirmed in post Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 20 only following completion of a satisfactory CRB check, and satisfactory check of the Protection of Vulnerable Adults register. Information contained within the personnel records confirmed this. Holme House DS0000026273.V375435.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good management systems in place that enable the manager to monitor, audit and review the care and support being given at Holme House. Poor judgement in the area of admissions into the home by the management team has had a detrimental impact upon the quality of service provided to some people at the home, and in turn upon the quality rating of this service. EVIDENCE: The records held by the Commission show that the manager is registered with us. The records show that she undertakes periodic training and discussions about the care home, and the people living at the home demonstrated that she Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 22 is familiar with conditions and issues facing the people living at the home. The registered manager explained that management structure, which showed there are clear lines of accountability and responsibility. A discussion took place with the registered manager concerning the admission of two people with overriding dementia care problems, and the impact this has had on not just them, but other people living at the home. The registered manager agreed that in this instance, a mistake had taken place, and she gave details of the actions she has taken to rectify the situation. These included; ensuring the staff were observing people more closely; liaison with the relatives of the 2 people recently admitted; referrals to the safeguarding team at the local authority; meetings with social workers; notifications to the Commission; improvements of the home’s admission policies and procedures. We made the point that a failure to observe the standards relating to admissions to the home had taken place; appropriate actions had been taken to remedy the situation, and that improvements to the admissions procedure would help to ensure inappropriate admissions did not take place in the future. The records show that the registered manager and staff make sure that so far as is reasonably practicable, the health, safety and welfare of people is promoted. Information contained within records held at the home shows that this is done by way of staff training, fire safety system testing, including emergency lighting, risk assessments and safety system monitoring. Staff explained that they take part in fire drills, and have received fire safety training, along with health and safety training. The records supported this. The records show that the home has insurance cover in place, with certificates on display. The systems relating to the safekeeping of people’s monies and valuables were found to be in good order. However, as previously mentioned within this report, the registered person should ensure that there are satisfactory safeguards in place to protect people’s financial interests with reference to the weekly activities fund. We made the point that these safeguards should be discussed thoroughly with all stakeholders, published and made available to people living at the home and their relatives. The staff said that they receive formal supervision, and the records confirmed this. The company has developed a quality assurance scheme that involves obtaining feedback from people at the home, their families and any visiting professionals. Once feedback is received, then a report on the quality of care will be published with an accompanying action plan (if required). Information held with the records at the home shows that monthly management visits take place by the service provider. Holme House DS0000026273.V375435.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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 OP38 2 OP9 13 (2) Regulation 14 Requirement The registered person must ensure that there are robust procedures in place to ensure that people unsuitable for admission are not admitted. The registered person must ensure that the polices and procedures for the safe handling and storage of medication held at the home are robust and implemented. The registered person must ensure that the home is conducted so as to make proper provision for the health and well being of people living there, and must ensure that as far is reasonably possible, people are protected against abuse. Timescale for action 08/07/09 08/07/09 3 OP18 OP38 12 13 (4) 08/07/09 Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 25 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 OP28 Good Practice Recommendations Staff should continue working towards achieving NVQ level 2 certificates. The registered manager should ensure that in her day to day of managing the service, she meets all standards applying to her as the registered manager. The registered person should ensure that there are satisfactory safeguards in place to protect people’s financial interests with reference to the weekly activities fund. These safeguards should be discussed thoroughly with all stakeholders, published and made available to people living at the home and their relatives. 2 OP31 3 OP35 Holme House DS0000026273.V375435.R01.S.doc Version 5.2 Page 26 Care Quality Commission St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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