Inspection on 24/05/07 for Holme Lodge Care Home

This inspection was carried out on 24th May 2007.

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 found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holme Lodge Care Home 21/10/08

Holme Lodge Care Home 24/10/07

Holme Lodge Care Home 26/04/06

Holme Lodge Care Home 15/11/05

Holme Lodge Care Home 12/07/05

Holme Lodge Care Home 13/10/04

Holme Lodge Care Home 14/06/04

Holme Lodge Care Home 11/02/04

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

CARE HOME ADULTS 18-65 Holme Lodge Care Home 1 Julian Road West Bridgford Nottingham NG2 5AQ Lead Inspector 556Joanna Carrington Key Unannounced Inspection 24th May 2007 10:00 Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holme Lodge Care Home Address 1 Julian Road West Bridgford Nottingham NG2 5AQ 0115 9822545 0115 9825441 j.ollerenshaw@east-leonard-cheshire.org.uk www.leonard-cheshire.org.uk Leonard Cheshire 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) Vacant Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category PD Date of last inspection 31st August 2006 Brief Description of the Service: Holme Lodge is a care home providing care and support for up to twenty adults with a physical disability. There are residents living at Holme Lodge that may have a learning disability or a mental health difficulty in addition to their physical disability. All of the bedrooms are single; none are en-suite. The home is situated in Lady Bay, a residential area that is part of West Bridgford. There is a pub, local shop and bus stop very close by and the amenities of West Bridgford and the city centre are only a short bus ride away. Copies of inspection reports and other quality reports are available to residents and other stakeholders by request. The fees at the home are based on a pricing and costing tool, which means they are based on individuals’ needs. Currently, fees range from a minimum of £612.32 to a maximum of £969.83 per week. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over nine hours on 24th May 2007. Inspections focus on outcomes for people that use the service. In order to do this the main method of inspection used was ‘case tracking’ which meant three service users were selected and their care was tracked through discussion with them and with staff, checking their care records and observing practice. Altogether five residents and six staff members were spoken with. A brief tour of the premises took place to assess environmental standards and a sample of staff records were also looked at to make sure staff are trained and that checks were carried out on staff before they started working at the home. Information about a home that is collected before the inspection is also used to make judgements about a service. This information could include notifications, information from other professionals and users of the service or their relatives, and also from any surveys that are sent out. Nine surveys from residents and two surveys from relatives were returned as well as the pre-inspection questionnaire (PIQ), which the manager filled in and returned to the Commission before the inspection. What the service does well: Prospective service user’s needs are assessed before they move to the home in order to ensure the home is suitable. Service users can visit the home before deciding to move there. Service users can retain their own care plans in their bedrooms and are involved in developing their care plans. The staff team assist service users to keep in contact with family and friends. Specialist health and social care professionals such as occupational therapists and speech and language therapists are involved in service users’ care when appropriate, which assists the team in meeting service users’ various individual needs. Medicine management continues promoting the safety of service users. Procedures are followed in the event of an allegation of abuse or when a service user makes a complaint. This assures service users they are listened to and that they are protected. Recruitment procedures are followed properly which also means service users are protected. There is an excellent system in place for the training of staff, which helps to ensure that the joint and individual needs of residents are met. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Admission arrangements ensure the service can meet the needs of prospective service users however prospective service users cannot make an informed decision to move there if information about the service is not accurate. EVIDENCE: Out of the nine service user surveys that were returned to the Commission four stated they were not given a choice to move in and four out of the nine service users said they did not have enough information about the home before they moved in. This should no longer be the case given there is a statement of purpose and service user guide, both of which are currently being updated. Evidence identified in other outcome areas in this report indicate that the service provided is not always reflective of the Statement of Purpose. The manager has been identified as the registered manager in the Statement of Purpose, which is false information. The manager is temporary and not registered. The placing authority’s community care assessment was seen for all three residents’ case tracked. According to Leonard Cheshire policy and procedures the manager or care supervisor carries out an initial assessment in order to determine a provisional fee then during the first twelve weeks of a resident’s placement a comprehensive assessment is carried out which then confirms the Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 9 cost of the placement. Copies of this assessment for the case tracked residents were not available at the inspection. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans are not being reviewed, which means there is a risk service users’ needs will not be met. Supporting residents with risk-taking has improved, which enables residents to be more independent and to make decisions and choices in their lives. EVIDENCE: All three case tracked service users have care plans in place that cover aspects of their social, health and personal care needs. Service users spoken with confirmed they keep their own copy and that they have been involved in writing and reviewing the plans if they choose to. Some of the plans seen do include service users’ signatures. There is no evidence for two case tracked service users that their care plans have been reviewed for almost a year. The problem with the other case tracked service user is that there is no evidence on their care plan of how this service user’s needs have changed or increased since they moved to the home because rather than reviewing existing care plans they have been completely re-written. Staff spoken with demonstrated Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 11 an understanding of the needs of these service users however some information staff members shared had not been recorded on support plans. For example, a service user spoken with said there are certain things that he cannot eat, a staff member explained that the service user is advised to have a low cholesterol diet but this was not recorded on their care plan, another service user can become agitated when staff can not communicate or understand him; it is identified on a care plan that the service user can become agitated but there is no guidance on the care plan with how the staff team should support the service user if they become agitated. The daily records do show that the speech and language team are involved in finding ways to improve communication with this service user. With this support a more detailed communication plan can be developed. A staff member spoken with demonstrated an awareness of this service user’s communication needs in terms of how the service user shows they are for example unhappy, angry or unwell. This information must be included on a communication care plan. At the random inspection in August last year there was progress evident with the development of individual service users’ risk assessments. All four case tracked residents have risk assessments in place that are relevant to their chosen lifestyle and activities. One case tracked service user has a risk assessment for using craft tools because this is an activity they enjoy. Another case tracked service user has a risk assessment in place for how staff will support him if he chooses to leave the building unaccompanied and what measures are in place to promote his safety, such as having identity tags fitted to chair if he becomes lost. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The service continues failing to promote and uphold service users’ rights including the right to access the community and to a quality of life. EVIDENCE: The pre-inspection questionnaire confirms that there are a number of day centres, college and a drama group that service users access during the week. A service user spoken with reported that he goes to day centre twice a week. Another service user spoken with chooses not to go to a day centre or to college. Since the random inspection last August 2006 a social worker contacted the Commission expressing concerns that a service user they placed at the home was not getting enough opportunity to go out and to access the community. The care records show that this service user has been out for a walk and shopping twice in the last couple of months. Two service users spoken with Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 13 said that they rarely get to go out and if they do this has to be planned well in advance. On one of the returned surveys it comments “some more social activities please” and on three surveys three service users said they could not do what they wanted to do in the evening because they cannot get out. Five staff spoken with all shared frustration in that limited staffing levels is preventing service users going out. Comments included, service users “are not getting the social hours”, “people can’t go to Asda or something” and not being able to meet requests to go to the library, to the bank or to go out and buy a CD. Limited access to the community and public amenities has been an issue at the last two key inspections. The care records for the case tracked service users and visitors book indicates that there are regular visits from family and friends. A staff member spoken with explained that some service users are assisted to use the telephone by dialling the number for them. Service users spoken with confirmed that they talk to their friends and family on the phone and can see them in private. Service users spoken with reported that staff treat them with dignity and respect and “are very kind”. While talking with a service user in his bedroom a staff member walked straight in without knocking, then apologised for not knowing that the service user was in there. The staff member came to the bedroom to borrow something from the service user. If the service user had not been in there then the borrowed item would therefore have been taken without permission. Not gaining permission to enter service users’ bedrooms has been observed at two previous inspections. The pre-inspection questionnaire and menu plans attaches indicate that a variety of healthy meals are offered and there are always two choices of meals offered. Service users had mixed comments about the meals; some said they were nice while others said they were ok and “so-so”. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels are inadequate for ensuring service users receive personal support that is flexible to their needs and preferences. General health of service users is not being checked, which means their overall health is at risk of not being maintained. Medicine management promotes the safety of service users. EVIDENCE: A service user spoken with likes to have two cups of tea before being assisted to get up and dressed. A staff member spoken with reported this and it was also recorded in the service user’s care plan. One service user was still in bed in the afternoon because the staff team had been too busy to get her up. Staff members spoken with expressed their frustration at “not giving the care that we should”. It was evident from talking with staff members, service users and from the correspondence seen that healthcare professionals such as speech and Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 15 language therapist, occupational therapist and physiotherapist are involved in service users’ support when appropriate. Evidence on the care plans seen suggest that service users are not getting regular healthcare checks. On the appointment record for one service user there was no entries for dentist, optician or general check up. The service user, when spoken with could not remember when they last went to the dentist. The storage of medication was well organised. Copies of prescriptions and ordering forms are kept so that there is an audit trail to ensure medicines are being administered as prescribed. The medicines in monitored dosage systems that were checked have all been given correctly. The remaining tablets in a boxed medication correlated with the quantity received at the start of the cycle and with what had been signed as given. The quantity of a ‘when required’ medicine was not accounted for on the medication administration record because the MAR only stated ‘none supplied this month’, the remaining quantity from the previous cycle had not been carried forward. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are assured that concerns, complaints and allegations are taken seriously and acted on. EVIDENCE: All service users spoken with at the inspection confirmed they are aware of the complaints procedure, who to complain to and feel confident their complaint would be listened to and acted on. The pre-inspection questionnaire stated there have been no complaints made since last inspection, which the care supervisor confirmed was still applicable at the time of this inspection. Staff spoken with demonstrated an understanding of the Nottinghamshire Safeguarding Adults procedures, what constitutes abuse of vulnerable adults and of their responsibilities to alert the manager of any allegations of abuse. Since the last inspection a safeguarding adults investigation has been undertaken and it was proved that a staff member had inappropriately treated service users. There was evidence seen that the safeguarding adults procedures were followed and the staff member in question has been referred to the POVA list. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The overdue re-provisioning of the service has left service users living in an environment that is not adequately homely or comfortable and does not meet their needs. EVIDENCE: The project manager for the re-provisioning of the service was last in contact with the Commission to update on any progress with the re-provisioning and re-development of the service in January this year. The care supervisor reported that planning permission has still not been gained in order to re-build the service as supported living. The intention to re-provision the service was identified at an inspection back in February 2004. A requirement was made in respect of this with timescale April 2007, which has been repeated in reports since. This timescale has now passed. A service user comments in their survey, “the re-provisioning is long overdue.” Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 18 The dining room and lounge area is only accessible to some service users via a lift. The tea-making area and facilities is not wheelchair accessible so most service users are not able to make their own drinks when they want one. At the last key inspection a requirement was made to ensure the premises are reasonably decorated throughout prior to the re-provisioning of the service. At the random inspection in August last year no progress had been made with this requirement. The pre-inspection questionnaire confirmed that still no further work has been done to the décor and environment. As stated in the last key inspection report, in some parts of the home paint is crumbling or has come off walls, plaster has not been painted over. The paintwork and general décor of the home is looking very outdated and in need of freshening up. The care supervisor reported that the manager has got funding for the work and quotes are being obtained but there was no evidence available at time of the inspection. Two returned surveys commented that the home is only ‘sometimes’ fresh and clean. On the day of the inspection areas of the premises seen, including bathrooms were clean and hygienic. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 33, 35 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There are good arrangements in place for the training of staff and improvements to recruitment procedures means that service users are now protected. However, poor staffing levels and not enough support for staff impacts negatively on service users and does not ensure their needs are met. EVIDENCE: There is an excellent computer database system in place that monitors the training needs of staff. It highlights when mandatory refresher courses such as moving and handling and food hygiene are due and lists all the training courses available and when they have been attended. These include Sexuality and Relationships, Disability and the Law and Complaints and Whistle blowing. Staff reported that training opportunities are good. The training matrix shows that sixty-seven percent of the staff team are qualified to at least National Vocational Qualification (NVQ) level 2 Social Care. Four staff members were randomly selected and their staff files were examined. All four staff files contained evidence that a criminal record bureau Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 20 check and two written references were obtained before each staff member commenced employment. Staff members spoken with reported there are currently a lot of changes going on with regards to the arrangements and structure of staffing. As a result contracted hours of staff have been reduced and some people have volunteered for redundancy. Despite this difficult time two staff members spoken with reported that they have not had supervision for a long time. Two of the staff files looked at did not have records of supervision since June 2006. The care supervisor reported that some senior staff members that are supervisors keep the supervision records, which means evidence is not available for inspection. At the last key inspection a requirement was made to review staffing levels because it was questioned whether three staff on a shift is an adequate number given the layout of the home, the mobility and care needs of residents and limited community access. At the random inspection in August 2006 the duty rota showed that the majority of shifts were now running with four staff members. The rota seen at this inspection showed that seven shifts in May only two staff members are working in the evening. All staff members spoken with expressed concern about staffing levels, “not giving the care we should” and “depends on shift if can talk with residents.” Four of the twelve returned surveys make reference to needing more staff. Service users spoken with reported that the home is often short staffed and that you have to sometimes wait a long time to get up or get help with eating. A service user commented, “if staff are busy will hang on for half hour… just got to put up with it.” Evidence in previous sections of this report also indicates that staffing levels are not appropriate to the needs of service users. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Although there are good systems in place for quality monitoring this does not benefit service users because standards cannot improve due to inadequate management cover at the home. EVIDENCE: The manager that was recruited in July 2006 and was expected to register as manager left their position in February this year. The Commission was informed that as a temporary arrangement a registered manager of another Leonard Cheshire service would be providing managerial cover three days per week until full time, permanent cover is found. That was almost six months ago and the Commission has heard nothing more on these interim arrangements and what is happening in the long term. There have been persistent problems with morale and the running of the home, as highlighted in the previous three inspection reports. There has not been a registered Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 22 manager for two years. Both staff members and service users spoken with are not happy with the lack of management cover. A service user commented that the home is not the same as it was, “gone down hill and can’t go down any further,” and another service user said “Nichola is nice and will listen to me but its shame only here two to three days per week.” The care supervisor is being given management tasks that are beyond the role of care supervisor and when asked if she has had any supervision, the care supervisor reported that she had not. The home had a thorough internal audit just prior to the last key inspection. The audit took place over one week and as a result a comprehensive report was completed along with required action to be taken. Since then, as part of the registered provider’s procedures for quality monitoring the manager had to do a self-assessment on all aspects of the quality of service. Since the selfassessment was completed there has not been a full time manager and staff shortages mean that action required has not been achieved. The pre-inspection questionnaire indicates that the servicing of gas, electrical systems and hoists and adaptations are up to date. The pre-inspection questionnaire showed that a fire drill was due. The fire safety records were examined at the inspection and showed that a recent fire drill has been carried out successfully. There were gaps, however in fire alarm testing between 19/04/07 and 04/05/07, 16/02/07 and 09/03/07 when there should be one undertaken weekly. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 X 15 3 16 1 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 1 X 3 X X 2 X Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 24 NO 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 YA6 Regulation 15 Timescale for action Care plans must be reviewed and 01/08/07 updated at least every six months. This is to ensure that all needs of service users are met. Enable service users to be a part 01/09/07 of the local community and to engage in local, social and community activities. Staff members must not walk 24/05/07 into service users’ bedrooms without knocking and seeking permission first. Service users must be treated in a manner, which respects their privacy and dignity at all times. Service users must receive their 24/05/07 personal support in a way that takes into account when and how they want it. This is to promote and protect service users’ rights and independence. Make sure service users have 01/09/07 regular health care checks. Ensure the premises are 01/10/07 reasonably decorated throughout. This is an outstanding requirement from two previous inspections, initial timescale 31/08/07 not met. DS0000008697.V335286.R01.S.doc Version 5.2 Page 25 Requirement 2 YA13 16 3 YA16 12 4 YA18 12 5 6 YA19 YA24 12 23 Holme Lodge Care Home 7 YA33 18 8 YA36 18 9 YA37 8, 18 10 YA42 13 Staffing levels must be appropriate to the number and needs of service users, the statement of purpose and size and layout of service. This is to ensure the safety and welfare of service users. All staff members must be regularly supervised. This is to ensure they have the necessary support to carry out their role and to ultimately meet the needs of service users. There must be a registered manager working at the home providing management cover, at a level, which is appropriate to the needs, numbers and health and welfare of service users. This is to ensure the home is well-run and in service users’ best interests. Fire alarm testing must be carried out weekly in accordance with fire safety legislation, to promote and protect the health, safety and welfare of service users. 24/05/07 01/09/07 01/09/07 24/05/07 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 Refer to Standard YA1 YA6 YA20 Good Practice Recommendations The Statement of Purpose must reflect the service provided in the home. Develop further communication care plans for service users with communication needs. Carry forward any remaining stocks of medication onto current medication administration records so that there is an audit trail. Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Holme Lodge Care Home DS0000008697.V335286.R01.S.doc Version 5.2 Page 27 - 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. 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